United States
Form Approved:
OMB No. 3206-0206
Office of Personnel Management
Retirement Operations
Washington, D.C. 20415-0001
Evidence to Prove Dependency of a Child
To establish eligibility for a child to receive survivor benefits, the law requires us to obtain proof that the child was financially
dependent on the deceased Federal employee or annuitant. Please read the instructions and submit the evidence for our
consideration. We can take no further action on your claim until we receive the required evidence.
A. Did a court order the deceased to provide support for
the child? If not, skip to item B below. If so, provide us
a certified copy of the court order; no other documents
are needed to prove dependency.
B. Did the child live with the deceased in a regular
parent-child relationship at the time of the employee’s
or annuitant’s death?
1. If not, skip to item 2 below. If so, you and at least
two other people who are not related to you or
the deceased must provide notarized affidavits
showing:
a. That the child lived with the deceased in a
regular parent-child relationship.
b. The length of time the parent-child relationship
existed.
c. That the deceased exercised parental
authority, responsibility, and control over the
child.
d. How the person is in a position to know the
facts.
The affidavit must show the name and address of
the person making the statement. Submit separate
affidavits for each child. All affidavits must be
sworn to or affirmed before a notary public or other
officer who is authorized to administer oaths.
2. If the child did not live with the deceased in a regu
-
lar parent-child relationship, you must show that
the deceased made regular and substantial contri
-
butions toward the child’s support. To prove this,
provide one or more of the following:
a. Evidence of eligibility as a dependent child for
benefits under other state and Federal
programs.
b. Proof of inclusion of the child as a dependent
on the deceased’s income tax returns for the
years immediately prior to death.
c. Canceled checks, money orders, or receipts of
periodic payments from the deceased for the
child.
d. Evidence of goods or services which show the
deceased made regular contributions of
considerable value to the child’s support.
e. Proof of coverage of the child as a family
member under the deceased’s health benefits
enrollment.
f. Other proof of a nature similar to the above
that demonstrates support of the child by the
deceased.
Warning: All evidence is subject to verification by Federal investigators. Any intentionally false
statement, concealment of a material fact, or willful misrepresentation relative to this claim is punishable
by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both (18 U.S.C. 1001).
Public Burden Statement: We estimate this form takes an average of 60 minutes per response to
complete, including the time for reviewing instructions, getting the needed data, and reviewing the
completed package. Send comments regarding our estimate or any other aspect of this form, including
suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement
Services Publications Team (3206-0206), Washington, DC 20415-3430. The OMB Number, 3206-0206,
is currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.
Thank you for your cooperation.
Retirement Operations
RI 25-37
Prior editions are not usable.
Revised May 2012
