Form Sf 2800 – Fill Out and Use This PDF

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 docu- ment prepared by the deceased.)

Section A - Information About the Deceased

6.If deceased had ever applied for or received retirement benefits, show the retirement claim number.

7.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.

8.See the pamphlet entitled “Applying for Death Benefits Under the Civil Service Retirement System” to help you determine which block to check.

10.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 con- nection 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

Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices

	Standard Form 2800
Previous editions are not usable.	Revised November 2011

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 dates that each marriage began and ended.

Section E - Information About the Deceased Person’s Dependent Children

1.a. List, in order of birth date, all the surviving, unmarried, dependent children of the deceased. List all such children you know of, no matter where they live. A dependent child is a son or daughter who is unmarried and:

•was under age 18 at the time of the deceased person’s death, including any:

1.adopted child, and/or

2.stepchild, and/or

3.recognized child born out-of-wedlock who lived with the deceased in a regular parent-child rela- tionship, and/or

4.recognized child born out-of-wedlock if there was a judicial determination of support or if the deceased made regular and substantial contribu- tions for the support of the child.

•is age 18 or older and unmarried, but who became mentally and/or physically disabled before age 18 and who, because of the disability, is incapable of self- support.

•is between ages 18 and 22, unmarried, and a full-time student in a recognized educational institution.

b.Attach a copy of the birth certificate for each child for whom you are applying.

d.Show how each child is related to the deceased. For example, write “Child of marriage at death” for a child of the deceased person’s marriage in force at the time of death.

e.If the unmarried dependent son or daughter is 18 or over, state whether he or she is a full-time student and/or disabled. Adult children may submit separate applications if they want separate payments made to them.

2.The mother of the unborn child, the legal guardian or the person responsible for the child should send us the birth certificate, when available.

3.d. If the person(s) in 3b. is(are) court appointed, indicate by checking the “Legal Guardian” box. If you are the person who is court appointed, attach a copy of the court appointment to this application. If there is no court appointment, check “Other” and write in the relationship to the child, for example, mother, father, sister, etc.

Section F - Information About Other Heirs

Please give us information about other relatives who may be able to inherit from the deceased. If you can’t give complete information, do the best you can. List only people who were living when the deceased died and who have the following relationships to the deceased:

•Widow(er) (unless named in Section C);

•Children of the deceased not included in Section E and the children of any deceased children (on a separate sheet of paper, show the relationships of descendants of deceased children to the deceased, for example, John and Mary, children of deceased son John, and Sue, child of deceased daughter Ann);

•If there is no living widow(er) or child, list the deceased person’s parents (if only one parent survives, a copy of the deceased parent’s death certificate should be attached, if available);

•If there are no living relatives of the deceased as described above and no court-appointed executor or administrator as described in Section G, list other relatives who can inherit from the deceased. The people you list must be blood kin of the deceased.

Section G - Information About the Deceased Person’s Estate

1.If someone was named as executor or administrator in the deceased person’s will, but is not appointed by a court, check “no.” If you have been appointed by a court, attach a copy of the court appointment.

Section H - Active Military Service

You do not need to complete parts 1 and 2 of this section if the deceased was retired at the time of death, since OPM already has this information.

1.Indicate whether the deceased performed active duty that terminated under honorable conditions in the Armed Forces or other uniformed services of the United States. Inactive service in reserve components of the uniformed service is not creditable for retirement purposes. Service in the National Guard is not usually considered active Federal military service except when ordered to active duty in the service of the United States and during an initial (3 months or longer) training period. However,

full-time National Guard duty is creditable, if the service interrupts creditable civilian service and is followed by reemployment (as explained in Chapter 43 of title 38) that occurs on or after August 1, 1990.

If you have a copy of the deceased person’s DD 214s or other discharge certificate(s) showing the dates of active duty and the deceased was an employee at the time of death, you should attach it (them) to your application.

2.Persons who performed active military service after December 31, 1956, must pay or have paid a deposit to receive credit for the military service.

If the deceased was an employee at the time of death, you may pay or complete the payment of the deposit by com- pleting the election form contained in SF 2800A, which can be obtained from the agency where the deceased was last employed. The agency can provide you with more information about this deposit.

3.Indicate whether the deceased ever received or applied for military retired pay.

If you are receiving military survivor benefits, the deceased person’s military service is used for survivor purposes, subject to a reduction equal to the amount of your military survivor benefits. However, if such retired pay was awarded on account of a service-connected disability incurred in enemy combat or caused by an instrumentality of war in the line of duty during a war period, or was awarded under title 10, U.S. Code Sections 12731 through 12739, (formerly Chapter 67, title 10) (reserve retired pay at age 60 based on 20 years of active and reserve service), no such reduction is

required. You should attach a copy of your award of military survivor benefits to show that the award was based on one of the above reasons.

Section J - Certification

1.Sign your name in ink. Please note that OPM will not accept the signature of someone who has a power of attor- ney for the applicant named in Section B. A court- appointed fiduciary can apply on behalf of the applicant, provided a court-certified copy of the court appointment is attached to the application for death benefits. If there is no court-appointed fiduciary and the applicant is not com- petent, a relative or person responsible for the applicant may sign. OPM will arrange later for the appointment of a representative payee for the person named in Section B.

Section K - Applicant’s Checklist

Use this section of the application to ensure that all required supporting documentation is attached.

SF 2800A

If the deceased was an employee at the time of death and you are the surviving spouse or former spouse, you and the deceased person’s agency should complete Standard Form 2800A, which can be obtained from the deceased person’s employing agency. Instructions for completing SF 2800A are contained on the form itself.

No

Yes		Any uncashed checks must be returned to the Treasury.
		It is a violation of law for anyone to withdraw payments deposited after the death of the deceased
		named above.

1a. Date of marriage to the deceased (mm/dd/yyyy)

1b. Date of divorce or annulment from the deceased (mm/dd/yyyy)

1.Full name of relative

2.Complete address

3.Relationship to deceased

4.Social Security Number if known

1.Has an executor, administrator or other official been appointed by the court to settle the estate of the deceased?

No		Go to item 3 below		Yes

2.Full name and address of person appointed

3.If an executor, administrator or other official has not been court appointed, will one be appointed?

Yes

No

1a. Branch of service

1b. Dates of active duty

From	To

2. If any of the above listed service was performed after 12/31/56, was a deposit
made to the Retirement Fund for the service?	Yes

No

Don't know

2.Do you want to have your survivor annuity payments made to the same checking or savings account to which OPM made payments

by Direct Deposit to the deceased before his or her death (must be an active account and you must be a co-owner)?	Yes

3.Do you want your survivor annuity payments made to a checking or savings account to which we have not already been making

payments by Direct Deposit?	Yes

4.Financial institution routing number (You may obtain this number by calling your bank, credit union, or savings institution.

This number is very important. We cannot pay by Direct Deposit without it. We suggest you call your financial institution to verify this number.)

5. What kind of account is this?					6. Account number
		Checking		Savings

7.Name and address of your financial institution

8.Telephone number of your financial institution (including area code)

No

No