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
FERS BASIC DEATH-IN-SERVICE

1. Employee’s Full Name:__________________________________________________

2. Other Names Used:____________________________________________________

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

5. Date of Birth: ____/____/____ 6. Total Creditable Service ____Years____Months

7. Final Salary: $_________ 8. Average High 3 Salary: $______________

9. Is this a Part-Time Case? ____Yes ____No 10. If Yes, give Tour of Duty at Death______

11. Retirement Code: ____ 12. Was Death Due to Work-Related Illness or Injury? __Yes __No

13. Spouse’s Name: __________________________________________________________

14. Date of Birth: ____/____/____ 15. Date of Marriage: ____/____/____

16. Spouse’s Social Security Number: ____ - ____ - ____

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

18. Mailing Address of Spouse: ____________________________

____________________________

____________________________

____________________________

19. Agency Name: ________________________________________________________

20. Agency Mailing Address:________________________________________________

________________________________________________

________________________________________________

21. Name of Agency Contact:________________________________________________

22. Commercial Telephone Number of Contact: (___)___________ 23.Fax:(___)__________

24. Email Address: ______________________________________

25. Name of Payroll Office Contact: __________________________________________

26. Commercial Telephone Number of Contact: (___)_____________ 27. Fax:(___)__________

28. Signature of Certifying Official: _____________________________________

29. Printed name of Certifying Official: _________________________________

SUBMIT COMPLETED FORM TO OPM AS SOON AS POSSIBLE - FAX to (724) 794-1112