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Application For Death Benefits (Civil Service Retirement System) Form. This is a Official Federal Forms form and can be use in Standard US Office Of Personnel Management.
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Application for Death Benefits Civil Service Retirement System Civil Service Retirement System This application is for use by persons applying for benefits which may be payable under the Civil Service Retirement System (CSRS) because of the death of an employee, former employee, or retiree who was covered by CSRS at the time of his/her death or separation from Federal service. You should have received an informational pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System" SF 2800-1, with this application. If you did not receive the pamphlet and the deceased was a Federal employee at the time of his/her death, you should get a copy from the deceased's employing agency. If the deceased was retired or a former employee not yet receiving a retirement benefit, you should get a copy from the Office of Personnel Management (OPM). You can write to the Office of Personnel Management at OPM, P.O. Box 45, Boyers, PA 16017-0045, call OPM's Retirement Information Office at 1-888-767-6738, or send us email at email@example.com. If the deceased was an employee at the time of death, send your completed application, with any attachments, to the personnel office in the agency where the deceased was last employed. If the deceased was a former employee or annuitant at the time of death, send it to the Office of Personnel Management, P.O. Box 45, Boyers, PA 16017-0045. If your address changes before we give you a survivor annuity claim number, notify us in writing and give your name, date of birth, your Social Security Number, and the deceased person's name, date of birth and Social Security Number. If you have received your claim number, notify us of the change by calling or writing as described above. Be sure to refer to your claim number. Instructions For Completing Application Type or print clearly in ink. If you need more space in any section, use a plain piece of paper with your name, date of birth, and Social Security Number, and the deceased person's name, date of birth and Social Security Number, written at the top. If you do not know an answer, write "unknown." If you are unsure of information (for example, if you do not know an exact date), answer to the best of your ability, followed by a question mark (?). The following additional information should help you to answer those questions on the application which are not entirely self-explanatory. Section B - Information About the Applicant 5. If you checked "designated beneficiary" and have a copy of the form designating you as beneficiary, attach it to the application. If you checked "parent," both parents must submit completed applications. If one is deceased, attach a copy of the death certificate. Otherwise, provide name and address of other parent in Section F, if known. If you checked "executor or administrator of estate," attach a copy of the court order appointing you executor or administrator. (Note that a court must have appointed you; we will not pay you based on a will or other document prepared by the deceased.) Section A - Information About the Deceased 6. 7. If deceased had ever applied for or received retirement benefits, show the retirement claim number. Recurring payments from the Office of Workers' Compensation Programs, U.S. Department of Labor (OWCP) and CSRS survivor annuity benefits usually are not payable for the same period of time. If the deceased had applied for or received benefits from the OWCP based on an illness or injury received resulting from a condition of employment within the last two years, indicate here. The OWCP claim number appears on the U.S. Treasury checks and correspondence from OWCP. See the pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System" to help you determine which block to check. If the deceased had no former marriage, write "none." Attach copies of death certificates and complete copies of court orders of divorce or annulment if these occurred on or after May 7, 1985. If you are the spouse of the deceased and you and the deceased were married more than one time, be sure to show the date your prior marriage(s) ended. Section C - Information About the Deceased Person's Spouse 1. Attach a copy of your marriage certificate. If you were married by a priest, rabbi, pastor, Justice of the Peace or other person empowered by the State to perform marriages, check "Clergy/Justice of the Peace". If you were not married by someone empowered by the State to perform marriages, check "Other" and explain (for example, "common law" or "tribal marriage"). If marriage is common law and a State court has determined that you were married, send a copy of the court order or judgment. If you do not have a court order or judgment, attach two notarized affidavits from persons who are in a position to know the facts and clearly state: (1) the relationship between you, your spouse, and the person swearing to the affidavit; (2) the length of time you and the deceased lived together; (3) the address or addresses at which you resided while you lived together; (4) whether there was any public announcement in connection with your common law marriage; (5) whether you and the deceased were regarded among your neighbors, friends, and relatives as being husband and wife during 8. 10. Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices Previous editions are not usable. Standard Form 2800 Revised November 2011 American LegalNet, Inc. www.FormsWorkFlow.com the time you lived together; and (6) how the person swearing to the affidavit is in a position to know the facts being presented in the affidavit. In addition, your own affidavit is required. It should state: (1) the date on which, and the State in which, you and your spouse mutually agreed to become husband and wife; (2) whether you or your spouse were ever married, ceremonially or under common law, to anyone else before entering into the common law relationship (if so, state in your affidavit all the facts of each previous marriage, including the date it took place and the date of the death or divorce that ended it); and (3) any other facts you believe will help prove you were husband and wife. You may also submit other documents which show a husband and wife relationship such as a naturalization certificate, deeds, immigration records, insurance policies, passports, child's birth certificate, income tax returns, etc. 2. If you married the deceased more than once, give dat