ClAIM FOR UNPAID COMPENSATION OF DECEASED MEMBER OF THE UNIFORMED SERVICES 

General Info 	 to all claimants by 

the employin! Example: Not Designated (Siblings, Children of Siblings) oyed at time of 

death. 

Part A. 

1. Neme(sl and social security 

numberlsl of claimant(s) 

Joseph Smith 

I 23-45-6789 

2. Relationship to deceased 

Brother 

3. If minor, state age 

4. Is designation of beneficiary for unpaid 

compensation on file with service? ? --­ (Y8$ or No) 

5. Are you named beneficiary? NO 

(Yes or No) 

6. Claimant(s) Stete of Legal Residence 

Ohio 

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

social security number of decedent 

MSGT John 1 Smith USMC 

8. Date of Death 

6/30/2010 

9. Name of Service 

USMC 

10. Decedent's domicile 

California 

Part B (To be completed by the w1dow or widower 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 aher 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 

No Spouse, No Children 

l"o Parents 

No Estate, No trust 

Joseph Stmth 

No other siblings 

Age 

70 

Relationship to 

Deceased 

Brother 

Address 

123 Main St 

Capitol, OH 44444 

(Continued on other side) Standard Form 1 174 (EGI

September 1 992 

4 GAO 26. 1 

(This form has been authorized for locel reproduction.) 
-------

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_o_n_e_________ 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 

N/A 

(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 witnesses are required, but a court certificate evidencing your appointment 

must be submitted. 

2. 	 If no administrator or executor has been appointed, w ill one be appointed? NO 

(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? Yes (If paid, receipted bill of the undertaker must be attached hereto.) 

(Yes or No) 

Whose money was used to pay the funeral expenses? Decedent's Money ----------~-------------------------------

FINES, PENAL TlES, and FORFEITURES are im,posod by law for the making of false or fraudulent 

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

(Signature of claimant) 	 COate! 

123 Main St 

(Street address) (Street address) 

Capitol, OH 44444 Phone(555)555-5555 

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

TWO WITNESSES ARE REQUIRED 

(Name(s) of claimant(s)J 

(Signature of witness) 

456 Willow Dr 	 456 Willow Dr 

(Street address) 	 (Street address) 

Capitol, OH 44444 	 Capitol, OH 44444 

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

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