CLAIM FOR UNPAID COMPENSATION OF DECEASED MEMBER OF THE UNIFORMED SERVICES 

Generallnform»tin~ · • 

the employil Example: Multiple Beneficiary Using the Same Form ;hed to all claimants by 

employed at time of 

death. 

Part A. 

1. Name{s) and social security 

number(s) of claimant {s) 

John Smith 

I 23-45-6789 

Judy Smith 

123-4§-6789 

2. Relationship to dec.eased 

Son 

Daughter 

3. If minor, state age 

4. Is designation of beneficiary for unpaid 

compensation on file w ith service? ? --­

{Yes or No) 

5. Are you named beneficiary? No --­

(Yes or No) 

6. Claimant{s) State of Legal Residence 

Florida 

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

social security number of decedent 

MSGT Jack Smith USMC 

987-65-4321 

8. Date of Death 

6/30/2010 

9. Name of Service 

USMC 

10. Decedent's domicile 

Florida 

Part 8 (To be completed by the w1dow or w 1dower of the deceased only.) Do you certify that you were married to the decedent 

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

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 the 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 the 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 Age 

Relationship to 

Deceased 

Address 

John Smith 123-45-6789 45 Son 123 Main St 

Sunkist FL 77777 

Judy Smith 123-45-6789 42 Dau 456 Main St 

Sunny City FL 77777 

Charles Smith 123-45-6789 38 Son 789 Main St 

Ocean View FL 77777 

Cheryl Smith 123-45-6789 35 Dau 159 Main St 

Water Crest GA 88888 

Standard Form 1 174 (EG) (Continued on other s•de) September 1992 

4 GAO 26. 1 

(This form has been authorized for local reproduction.) 
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SF 1174 (Back) 

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/A of the estate of the deceased, as evidenced by 

(Executor or administrator) 

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

(Name, address, and re ~ionship of interested relative or c.redit or) 

and such appointment is still in f ull force and effect. 

NOTE. •• If making claim as the executor or administrator of the estate of the deceased, no witnesses 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? ______Y_e_s_____ (If paid, receipted bill of the undertaker must be attached hereto.) 

(Yes or Nol 

Whose money was used to pay the funeral expenses? D ecedent's 

FINES, PENAL TIES, and FORFBTURES are 1m posed by law for the making of false or fraudulent 

claims against the United States or the making of false statements 

6/30110 

(Signature of claimant) 	 !Date) 

in connection therewith. 

6/30/1 0 

(Signa lUre of claimant) 	 (Date) 

123 Main St 	 456Main St 

(Street address) 	 (Street address) 

Sunkist FL 77777 Sunny City FL 77777 

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

TWO WITNESSES ARE REQUIRED 

We certify that we are well acquainted with the above __________________ 1_

1 ___ 1 Joh Sn i_th __& __Judy Smi ____ __th __ ________ and that 

(Name(s) of claimant(s))

the signature(s) ot the claimant(s) was (were) affixed in our presence. 

(Signature of witness) (Signature of witness) 

123 Main St Apt C 

(Street address) 

123 Main StAptD 

(Street address) 

Capitol, FL 44444 

(City, State. and ZIP code) 

Capitol, FL 44444 

(City, State, and ZIP code) 

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.