CLAIM FOR UNPAID COMPENSATION OF DECEASED MEMBER OF THE UNIFORMED SERVICES 

General In ' ~d to all claimants by 

the employ nployed at time of Example: Not Designated (Spouse, Children, Parents) death. 

Part A. 

1. Name(s) and social security 

number(s) of claimant(s) 

John J. Smith Jr. 

123-45-6789 

2. Relationship to deceased 

Son 

3. If minor, state age 

NIA 

4 . Is designation of beneficiary for unpaid 

compensation on file with service? ? -­- (Yes or Nol 

5. Are you named beneficiary? No 

(Yes or No) 

6. Claimant(s) State of Legal Residence 

Ohio 

7. Name, rank or rating, service number, and 

social security number of decedent 

MSGT John J. Smith Sr USMC 

987-65-4321 

8. Date of Death 

6/3012010 

9. Name of Service 

vSr"- c:.. 

10. Decedent's domicile 

California 

Part 8 (To be completed by the widow or wtdower of the deceased only.) Do you cert1fy that you were marned to the decedent 

and to the best of your knowledge and belief that the marriage was not dissolved prior to his/her death? 

WIDOW OR WIDOWER AND DESIGNATED BENEFICIARIES DO NOT FILL IN PART C. ALL OTHERS MUST. 

Part C 

1. List below the name, social security number, age, relationship, and address of: 

(a) Widow or widower. 

(b) If no widow or widower survives, list each living child of t he deceased (include natural, adopted, illegitimate, and stepchildren 

and indicate after their names which class) or the descendants of deceased children. 

(c) If no widow or widower, child or descendant of deceased children survives, list each surviving parent and state whether 

natural, step, foster, or adoptive parent. 

(d) If none of the above survives, list t he next of kin who may be capable of inheriting from the deceased (brothers, sisters, 

descendants of deceased brothers and sisters). 

Name and Social Security Number 

John J Smith Jr. (Only Child) 

N/A 

Age 

40 

Relationship to 

Deceased 

Son 

Address 

123 Main St. 

Capitol, OH 44444 

Standard Form 1 174 (EGI 

September 1992 

4 GAO 26.1 

(This form has been authorized for local reproduction.) 

(Continued on other Side) 
-------

SF 1174 !Backl 

Part D 

1. If none of the above survives and an executor or administrator has been appointed, the following statement should be completed: 

1/we have been duly appointed ________N__IA_________ of the estate of the deceased, as evidenced by 

(Executor or administratorl 

certificate of appointment herewith, administration having been taken out in the interest of 

(Name, address, and relationship of interested relative or creditor) 

and such appointment is still in full force and effect. 

NOTE. - If making claim as the executor or administrator of the estate of the deceased, no w itnesses are required, but a court certificate evidencing your appointment 

must be submitted. 

2. 	 If no administrator or executor has been appointed, will one be appointed? N/A 

(Yes or No) 

DESIGNATED BENEFICIARY, SURVIVING SPOUSE, CHILDREN, PARENTS, OR LEGAL REPRESENTATIVES DO NOT 


FILL IN PART E. ALL OTHER MUST. 


PartE 

Have the funeral expenses been paid? N/A (If paid, receipted bill of the undertaker must be attached hereto.) 

(Yes or No) 

Whose money was used to pay the funeral expenses? _N_I_A______ _________ __________ 

FINES, PENAL TIES, and FORFEITURES are Imposed by law for the making of false or fraudulent 

claims against the United States or the maki ng of false statements in connection therewith. 

6/30110 

!Date) (Signature of claimant) {Date} 

123 Main St Apt B 

!Street address) (Street address) 

Capitol, OH 44444 Phone(555)555-5555 

{City, State, and ZIP code) (City, State, and ZIP code) 

(Signature of claimant} 

TWO WITNESSES ARE REQUIRED 

We certify that we are well acquainted with the above _ __________J_o_hn_J_S_m_i_th_Jr_.__________ and that 

(Name(s) of claimant(s)} the signature(s) of the claimant(s) was (were) affixed in our presence. 

~i~~ David Watkins qGiA ~ Barb Johnson 

' ~nature of witness) COo:) (Signature of witness) 

123 Main St Apt C 123 Main St Apt D 

(Street address) (Street address) 

Capitol, OH 44444 Capitol, OH 44444 

(City, State, and ZIP code) (City, State, and ZIP codo} 

All Federal checks in possession of the claimant, drawn to the order of the decedent, in payment of pay and allowances should accompany this claim.