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DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard

APPLICATION FOR ANNUITY UNDER THE SURVIVOR BENEFIT PLAN (SBP),

RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP),

RETIRED SERVICEMANﾶＶ FAMILY PROTECTION PLAN (RSFPP) and/or

FINAL RETIRED PAY DUE

PRIVACY ACT STATEMENT

Ｄｑ｜＃ﾳｆｒｏｏｈｆｗｌｒｑ＃ｒｉ＃ｌｑｉｒｕｐｄｗｌｒｑﾴ＃ｄｖ＃ｇｈｉｌｑｈｇ＃ｌｑ＃ｗｋｈ＃Ｓｄｓｈｕｚｒｕｎ＃Ｕｈｇｘｆｗｌｒｑ＃Ｄｆｗ＃ｒｉ＃４＜＜８＃＋ｆｒｇｌｉｌｈｇ＃ｄｗ＃７７＃Ｘ１Ｖ１Ｆ１＃６８３４＃ｈｗ＃ｖｈｔ，＃ｒｑ＃ｗｋｌｖ＃form has not been approved by the Director of the Office of Management and Budget (OMB) and does not display a valid control number assigned by the Director. Therefore, no person shall be subject to any penalty for failing to comply with any such collection of information.

Authority: Collection of this information is authorized by: 10 U.S.C. Chapters 73 and 165; DOD Financial Management Regulation, Volume 7B, Chapters 30, 37, 49, and 54; and E.O. 9397.

Purpose: The Coast Guard Pay & Personnel Center will use this information to verify eligibility of a surviving spouse, dependent child, former spouse, or natural person with an insurable interest for an annuity under the Survivor Benefit Plan (SBP) and/or Retired Servicemans Family Protection Plan (RSFPP). The information will also be used to verify eligibility for final retired pay arrears due a deceased Coast Guard, PHS, or NOAA member.

Routine Uses: The information will be used by the Coast Guard Pay & Personnel Center to establish a survivor annuity account. The information may be shared with the Internal Revenue Service for tax purposes, and with the Department of Veterans Affairs in conjunction with administration of DVA compensation.

Disclosure: Disclosure of this information (including your SSN) is voluntary; however, failure to furnish the requested information will delay payment of annuities and final pay arrears.

PART ﾱ INFORMATION ABOUT THE DECEASED MEMBER

1.Name (Last, First, Middle Initial)

2. Employee ID Number

3. Date of Death

PART B ﾱ SURVIVING SPOUSE/FORMER SPOUSE, INSURABLE INTEREST INFORMATION

4.Name (Last, First, Middle Initial)

5. Social Security Number

6. Date of Birth

	7. Area Code and Telephone Number			8. Correspondence Mailing Address (including zip/postal code)					9. What is your country of citizenship?

	10. Were you legally married to the deceased at the time of death?								Yes	No

	10a.	If yes, provide, Place of Marriage:						10b. Date of Marriage:

	11. If former spouse, have you remarried? (If yes, provide place and date of remarriage)								Yes	No

	11a.	Place of Remarriage:						11b. Date of Remarriage:

	12. Are you receiving a survivor annuity on behalf of any other deceased military member?								Yes	No
	(If yes, provide deceased member's name, social security number, branch of service and monthly amount below)								Yes	No


	12a.	Name of Deceased Member				12b. Social Security Number	12c. Branch of Service			12d. Amount


	PART C ﾱ ELIGIBLE CHILDREN OF THE DECEASED UNDER THE AGE OF 23 OR INCAPABLE OF SELF-SUPPORT

	13a.	Name				13f. Name, Address, Relationship and Telephone Number of Custodian

	13b.	Social Security Number	13c. Date of Birth

	13d.	Marital Status	13e. Full-Time Student?			Relationship			Telephone
				Yes	No

	14a.	Name				14f. Name, Address, Relationship and Telephone Number of Custodian

	14b.	Social Security Number	14c. Date of Birth

	14d.	Marital Status	14e. Full-Time Student?			Relationship			Telephone
				Yes	No

	15a.	Name				15f. Name, Address, Relationship and Telephone Number of Custodian

	15b.	Social Security Number	15c. Date of Birth

	15d.	Marital Status	15e. Full-Time Student?			Relationship			Telephone
				Yes	No

CG-1884 (07/13)										Page 1 of 2

PART D ﾱ＃GUARDIAN INFORMATION

	16. Has a guardian been appointed by a court for any of the named survivors in Part B or C?	Yes
	If yes, provide a copy of the court order.	Yes
	If yes, provide a copy of the court order.

PART E ﾱ＃DIRECT DEPOSIT INFORMATION

17a.

17b.

Continue direct deposit to the same account used for member's retired pay. (Continue to Part F)

Direct deposit account shown below. (Complete blocks 18 through 19b or attach a blank voided check)

18.

Type of Account:

Checking

Savings

19a.

Routing Transit Number:

Check Digit

19b. Account Number

PART F ﾱ＃FEDERAL INCOME TAX WITHHOLDING INFORMATION

20.

I do not want any federal tax withheld from my annuity. (Continue to Part G)

21. Marital Status (check one):

Single,

Married or

Married but withhold at higher single rate

22. Total No. of Exemptions Claimed: ______________

23. Additional Withholding (optional): $ ______________________________

PART G ﾱ＃AFFIDAVIT AND SIGNATURE

24.I certify that all statements on this claim are true to the best of my knowledge, information, and belief. I certify that no evidence to the settlement of this claim has been suppressed or withheld. I understand that any false statement on this claim, or any misrepresentation relative thereto, is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 10 years or both (32 Stat. 197; 18 U.S.C. 10).

I understand under the law, I cannot receive both a CG, PHS, or NOAA Annuity and Dependency & Indemnity Compensation (DIC) in full amounts from the same retiree. I am only entitled to the amount of the CG, PHS, or NOAA annuity that exceeds the DIC spouse payment. If any overpayments of CG, PHS, or NOAA benefits occur, I authorize the Department of Veteran Affairs to repay the Coast Guard, PHS, or NOAA the Amount of the overpayment from the DIC payments to which I may become entitled.

24a. Date

24b. Signature of Applicant

WITNESSES REQUIRED ONLY IF SIGNATURE OF APPLICANT IS MADE Ｅ＼＃ﾳ［ﾴ＃ＰＤＵＮ＃ＤＥＲＹＨ１＃

Ｄｑ＃ｄｑｑｘｌｗｄｑｗ＃ｚｋｒｖｈ＃ｄｓｓｏｌｆｄｗｌｒｑ＃ｌｖ＃ｖｌｊｑｈｇ＃ｚｌｗｋ＃ｄｑ＃ﾳ［ﾴ＃ｐｘｖｗ＃ｅｈ＃ｚｌｗｑｈｖｖｈｇ＃＋ｅ｜＃ｗｚｒ＃ｇｌｖｌｑｗｈｕｈｖｗｈｇ＃ｓｈｕｖｒｑｖ，＃ｒｕ＃ｑｒｗｄｕｌ｝ｈｇ＃ｒｕ＃ｆｒｘｑｗｈｕsigned by the person holding power of attorney. A copy of the power of attorney and explanation why the annuitant required assistance must also be submitted

25.(PRINT) Witness Name (Last, First, MI)

25a. Witness Signature

25b. Witness Address (Street, City, State and Zip Code)

25c. Witness Telephone Number

25d. Date

26.(PRINT) Witness Name (Last, First, MI)

26a. Witness Signature

26b. Witness Address (Street, City, State and Zip Code)

26c. Witness Telephone Number

26d. Date

CG-1884 (07/13)

Page 2 of 2

Question	Answer
Form Name	Form Cg 1884
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	cg_1884 cg 1884 form

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