ATTACHMENT 5 

CSRS DEATH-IN-SERVICE QUICK PAY 

1. Employee’s Full Name:________________________________________________________ 

2. Other Names Used:__________________________________________________________ 

3. Date of Death: _____/_____/_____ 4. Health Benefit Code at Death: _______ 

5. Social Security Number: _____-_____-______ 6. Date of Birth: ____/____/____ 

7. Retirement SCD: __________ 8. Leave SCD: __________ 9. Final Salary: $__________ 

10. Is There Part–Time Service After 4/7/1986? _________Yes __________ No 

11. Active Military Service: _______ Years ______ Months _______ Days 

12. Military Deposit Paid: ____Yes ____ No 13. Date First Covered by CSRS: __________ 

14. Receiving Active Duty Military Retired Pay: ____Yes ____ No 

15. Is this a CSRS-Offset Case? ____Yes ____ No 16. Retirement Code: ________ 

17. Spouse’s Name: ___________________________________________________________ 

18. Date of Birth: ____/____/____ 19. Date of Marriage: ____/____/____ 

20. Spouse’s Social Security Number: ______ - _____ - ______ 

21. Spouse’s Telephone Number: Home (_____) ____________ Work (_____) ____________ 

22. Mailing Address of Spouse: ____________________________________ 

 ____________________________________ 

 

23. Children of the Deceased: Minor: ____Yes ____No How Many _____ 

 Student: ____Yes ____No How Many _____ 

 Disabled: ____Yes ____No How Many _____ 

24. Was Death Due to Work-Related Illness or Injury? ____Yes ____No 

 

25. Agency Name: ________________________________________________________ 

26. Agency Mailing Address:________________________________________________ 

27. Name of Agency Contact:________________________________________________ 

28. Commercial Telephone Number of Contact: (___) _____________ 29. Fax: (___)___________ 

30. Email Address: _____________________________________________________________ 

31. Name of Payroll Office Contact: _______________________________________________ 

32. Commercial Telephone Number of Contact: (___) _____________ 33.Fax: (___)___________ 

34. Signature of Certifying Official: _____________________________________ 

35. Printed name of Certifying Official: _________________________________ 

 

SUBMIT COMPLETED FORM TO OPM AS SOON AS POSSIBLE - 

FAX to: (724) 794-1112 or (724) 794-1220

09-102attachment5.doc Page 1 of 2 
FERS DEATH-IN-SERVICE QUICK PAY 

1. Employee’s Full Name:__________________________________________________ 

2. Health Benefit Code at the time of death: __________ 

3. Date of Death: _____/_____/_____ 4. Social Security Number: _____-___- _____ 

5. Date of Birth: ____/____/____ 6. Total Creditable Civilian Service ____Years ____Months 

7. Total Pre-57 and PAID Post 56 Military Service:____Years ____Months 

8. Is intermittent service involved?____Yes ____No 9. Full Time Final Salary: $_________ 

10. Full Time Average High 3 Salary: $___________ 

11. Was there ANY part-time service? ____Yes ____No 

12. Retirement Code: ______ 13. Was Death Due to Work-Related Illness or Injury?___Yes ___No 

14. Spouse’s Name: ____________________________________________________________ 

15. Date of Birth: _____/_____/_____ 16. Date of Marriage: _____/_____/_____ 

17. Spouse’s Social Security Number: ______ - _____ - ______ 

18. Spouse’s Telephone Number: Home (_____) ______________ Work (_____) _____________ 

19. Are there any dependent children of deceased? ___ Yes ___ No 

20. Mailing Address of Spouse: ____________________________ 

____________________________ 

____________________________ 

____________________________ 

21. Agency Name: ________________________________________________________ 

22. Agency Mailing Address: ________________________________________________ 

________________________________________________ 

________________________________________________ 

23. Name of Agency Contact: ________________________________________________ 

24. Commercial Telephone Number of Contact: (___) _____________ 25.Fax :(___) __________ 

26. E-Mail Address: ______________________________________ 

27. Name of Payroll Office Contact: ________________________________________________ 

28. Commercial Telephone Number of Contact: (___)_____________29. Fax:(___)__________ 

30. Signature of Certifying Official: _____________________________________ 

31. Printed name of Certifying Official: _________________________________ 

SUBMIT COMPLETED FORM TO OPM AS SOON AS POSSIBLE – 

 FAX to (724) 794-1112 or (724) 794-1220 

09-102attachment5.doc Page 2 of 2