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U.S.A. forms for U.S. Office of Personnel Management

BROWSE U.S. OFFICE OF PERSONNEL MANAGEMENT (GA) FORMS

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Form approved:
OMB No. 3206-0156
Documentation and Elections in Support of
Application for Death Benefits When
Deceased Was an Employee at the Time of Death
Civil Service Retirement System
Includes Information, Instructions and Necessary Forms
Information for Agency
This package should be completed if the deceased was an employee under the Civil Service Retirement System (CSRS) at the time of
death. All applicable forms in the package should be submitted to OPM with the survivor's application (SF 2800).
Information for Applicant
This package contains the forms that you and the deceased person's employing agency need in order to complete your Application for
Death Benefits (SF 2800) under the Civil Service Retirement System (CSRS). SF 2800A should be completed only if the deceased was a
Federal employee at the time of death. All applicable forms in this package should be submitted to the deceased person's employing
agency, along with your Application for Death Benefits (SF 2800). The agency will forward the application to OPM.
Section 1: Certified Summary of Federal Service
To be completed by deceased person's employing agency's personnel office with applicant's signature certifying that
information is complete.
Section 2: Information and Elections Regarding Post-1956 Military Service
To be completed by applicant, if appropriate.
Section 3: Agency Information and Certification
To be completed by deceased person's employing agency's personnel and payroll offices.
Privacy Act Statement
Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code), the Federal Employees Group Life Insurance law
(Chapter 87, title 5, U.S. Code), the Federal Employees Health Benefits law (Chapter 89, title 5, U.S. Code) and the Unemployment Compensation Amendments of
1992 (Public Law 102-318). The information you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain
additional information if necessary, to determine and allow present or future benefits, to maintain a uniquely identifiable claim file and to properly tax your benefits.
The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local
or other charitable or social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination or
continuation of benefits under this program or to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies
when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943), authorizes the use of the Social
Security Number. Failure to provide the information may delay or prevent action on your application.
Public Burden Statement
We estimate this form takes an average of 45 minutes per response to complete. Send comments regarding our estimate or any other aspect of this form, including
suggestions for reducing completion time, to the Office of Personnel Management, Retirement Services Publications Team (3206-0156), Washington, D.C.
20415-3430. The OMB number, 3206-0156 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is
displayed.
Standard Form 2800A
Office of Personnel Management
Revised March 2012
5 CFR 831
1
The December 2008 edition is usable.
Section 1 - Certified Summary of Federal Service
Agency Instructions
A certified copy of this form must accompany an Application for Death Benefits (SF 2800) for a deceased employee if a survivor annuity
appears to be payable.
Part A - Identification
1. Name of employee (last, first, middle initial) 3. Date of birth (mm/dd/yyyy) 4. Social Security Number
2. List all other names used (maiden name, AKA, spelling variants) 5. Other birth dates used 6. Military serial number
7. Service computation date for retirement purposes
Part B - Verified Service History Documented in Official Personnel Records
Federal Agency or
Military Service Branch
Appointment, Separation, or
Conversion Dates for Civilian and
Active Honorable Military Service
Name of Retirement
System*
(CSRS, CSRS Offset, etc.)
Remarks and Non-Creditable
Time**
* Give details of creditable civilian service not subject to retirement deductions in Part C.
**If service was performed on a WAE or intermittent basis, show the number of hours worked in Remarks. Give needed information if service is part time.
Standard Form 2800A
The December 2008 edition is usable.
2
Revised March 2012
Part C - Details of Federal Civilian Service Not Subject to
Contributory Retirement System
Detail below (1) any period of Federal civilian service subject only to "FICA" deductions and (2) any other Federal civilian service not
subject to a Federal employee (or D.C. government) retirement system. If total basic salary earned for any such period of service is known,
a summary entry may be entered on the right hand side below. Otherwise, show each change affecting basic salary during the period of
service. Service which was not subject to CSRS deductions is creditable only as specifically allowed by law.
Nature of action
(Appt, pro, res,
etc.)
Effective
date
Basic
salary rate
Salary basis
(per annum, per hour,
WAE, etc.)
Leave
without pay
If Basic Salary Actually Earned Is
Available, Make Summary Entry Below
From
Total
earned
To
Part D - Agency Certification
I certify that the information on this form accurately reflects verified information contained in official personnel and/or payroll records in
the custody of this agency.
Signature of authorized agency personnel official
Official title
Date
Telephone no. & area code
Agency name and address, including ZIP code
Part E - Applicant's Certification
Signature (do not print)
To the best of my knowledge, the service listed above is complete.
The employee had additional service. (If you claim the employee had additional service, attach a signed statement giving the dates,
position, title and location of employment, including agency, bureau and division. Claimed service cannot be credited for survivor
benefit purposes until it has been verified. This also applies to unverified service listed on a Statement of Prior Federal Service
(SF 144), or similar affidavit.)
Note: If the employee performed Federal civilian service subject only to Social Security deductions (FICA) or not subject to
retirement deductions, be sure that the agency has correctly completed Part C above.
Date
Standard Form 2800A
The December 2008 edition is usable.
3
Revised March 2012
Section 2 - Information for the Survivor of a Deceased CSRS Employee
About Service Credit for Post-1956 Military Service
Because your decision about completing the deposit for or including the deceased employee's military service in the survivor
annuity computation may affect your rights under the Civil Service Retirement System (CSRS), you need to be aware of the
following information.
A. If the Deceased Employee Was First Employed Under CSRS Before October 1, 1982
1. Optional Deposit
a. If you qualify at the employee's death for social security survivor benefits based on his or her service, you have the option
of either making the deposit to include the post-1956 military service in the CSRS survivor annuity computation, or not
making the deposit to exclude the post-1956 military service from the CSRS survivor annuity computation.
b. If you will qualify at a future date for social security survivor benefits based on the decedent's service, post-1956 military
service will be included in the computation of your CSRS survivor annuity until you become entitled (or would upon
application be entitled) to social security benefits. You have the option of making the deposit now and avoiding the
reduction in your CSRS survivor annuity or not making the deposit and having your annuity adjusted to exclude
post-1956 military service if you become eligible for social security benefits based on the decedent's service.
2. Eligibility for Social Security
A survivor of a deceased employee may be eligible for social security survivor benefits if the employee was "fully insured" and
the survivor is (a) the parent of an eligible child, (b) age 50 or over and disabled, (c) age 60 or over, or (d) a divorced spouse
age 62 or over. For information about your present or future eligibility for social security survivor benefits, contact the Social
Security Administration. NOTE: If you become ineligible for social security survivor benefits based on the deceased employee's
service (e.g., by becoming eligible for social security benefits based on your own earnings which exceed the survivor benefits),
you should contact OPM. You may be eligible to have the military service restored to the survivor annuity computation.
B. If the Deceased Employee Was First Employed Under CSRS After September 30, 1982, no credit is allowed for post-1956
military service unless a deposit is made for the service.
C. Factors that May Affect Creditability of Military Service Regardless of When the Deceased Was First Employed
1. Minimum Basic Annuity Provisions
If you are eligible for a CSRS survivor annuity based on the minimum basic annuity provisions of the law, it is possible that
the exclusion of credit for post-1956 military service will have no effect on the amount of your annuity. (See items 4 and 5 in
Part A of this form.) If you need more information about how you may be affected, contact the decedent's employing agency
representative named in item 7 of Part A of this form.
2. Effect of Military Retired Pay
a. If, at the time of death, the employee was receiving military retired or retainer pay that was (1) awarded because of a
service-connected disability incurred either in combat with an enemy of the United States or caused by an instrumentality
of war and incurred in the line of duty during a period of war, or (2) awarded under the reserve retiree provisions of
chapter 1223, title 10, U.S. Code sections 12731 through 12739 (formerly chapter 67 of title 10), you will receive credit
for the military service subject to the provisions for military deposit for post-1956 military service.
Standard Form 2800A
The December 2008 edition is usable.
4
Revised March 2012
b. If, at the time of death, the employee was receiving military retired or retainer pay that was not awarded under either of the
two exceptions noted in C.2.a., you will receive credit for the military service, subject to an important difference in the
computation of the benefits as described below. (1) If your deceased spouse arranged for you to receive a military
survivor benefit, your CSRS survivor benefit will be reduced by the amount of the military benefit. Since this reduction
will never be greater than the value of the military service under the CSRS benefit computation, you are not disadvantaged
by this requirement with respect to your CSRS benefit. (2) If you feel that it is not to your advantage to include the military
service in the computation of your CSRS survivor benefit, you may send OPM your written election not to include the
military service in your CSRS annuity computation now. (See Part C of "Survivor Election.")
D. Information About Deposit for Military Service
1. The amount of deposit is 7 percent of military basic pay (plus interest, if any).
2. If the deposit is made, the post-1956 military service will be credited under both the civil service and the social security systems,
if it is otherwise creditable.
E. If You Are the Survivor of a Reemployed Annuitant
1. If the deceased employee was reemployed while annuity payments were continuing and had less than 5 years of service as a
reemployed annuitant at the time of death, you may not make a deposit for the military service.
2. If the deceased employee had 5 or more years of service as a reemployed annuitant and you elect a recomputation of the annuity
under the law in effect at the time of death, you may make a deposit for post-1956 military service. However, if you elect a
recomputation of the annuity, a deposit must also be made to cover any of the decedent's service as a reemployed annuitant for
which no retirement deductions were made. Before you make your deposit ask the decedent's employing office for information
about how a recomputation will affect your annuity.
F. If You Elect To Pay the Deposit
1. If you do not have sufficient documentation of military basic pay earnings for the employing agency to determine the amount
due, the agency will tell you how to obtain an estimate of earnings from the branch of military service in which the decedent
served.
2. You should make payment to the agency as soon as possible. The agency will not delay processing of your application for death
benefits while you are waiting to receive an estimate of military earnings from the military service. If you have not made the
deposit before the agency sends the application to OPM, the agency will tell OPM that you plan to pay the deposit.
3. In order to credit your deposit, OPM must receive documentation of your payment from the agency before your application is
completely adjudicated.
4. If you elect to pay the deposit, but later decide not to do so, promptly notify the employing agency and OPM in writing so that
OPM can complete final processing of your application for survivor benefits.
Standard Form 2800A
The December 2008 edition is usable.
5
Revised March 2012
SURVIVOR'S MILITARY SERVICE ELECTION
Deceased Employee Covered by CSRS or CSRS Offset
I elect not to make (or complete) the deposit for post-1956
military service. I understand this decision is irrevocable after
OPM completes the processing of my application for survivor
benefits.
Part C - To be completed by survivor of deceased employee in receipt of military
retired pay at the time of death
8. Agency personnel office address to which form should be returned
I elect to exclude the decedent's military service from my survivor annuity.
6. Agency records show the above named deceased employee was first employed under the Civil Service Retirement System (CSRS)
and had post-1956 military service for which a deposit has not been made or has not been completed.
I elect to make (or complete) the deposit to the employing
agency for the decedent's post-1956 military service. I
understand that this deposit must be paid to the agency in a
lump sum. (Note: The election may be changed at any time
before the deposit is actually paid to the agency.)
5. Was a deposit account opened for the employee?
4a. If item 4 is "yes," would loss of credit for post-1956
military service reduce the amount of the annuity?
4. Is survivor eligible for an annuity based on the minimum basic annuity?
I have attached verification of my eligibility or ineligibility for military survivor benefits.
(Specify monthly amount, if known $ .)
Part A - To be completed by employing agency
1. Employee's name (last, first, middle initial) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number
Period of Military Service
No
Annuity will be based on
actual service
Yes complete information below
No
Amount due (with interest) Amount paid by employee Balance due
From To
7. Agency representative to contact for information
before October 1, 1982
on or after October 1, 1982
Part B - To be completed by survivor
Our records indicate that you might be eligible for a civil service survivor annuity. You have the right to make a deposit for the deceased
employee's post-1956 military service. Your decision may affect your rights under CSRS. Read the attached Information for the Survivor
of a Deceased CSRS Employee... carefully to be sure you understand the consequences of not making the deposit for military service. Then
make your election, sign and date the form, and return two (2) copies to the address shown in item 8 above. If you have decided to pay the
deposit, we will provide you with the necessary information. Payment must be made in a lump sum to this agency before the Office of
Personnel Management completes its adjudication of your application for survivor benefits.
Telephone number
Election must be received
by date (mm/dd/yyyy)
Survivor Election I have read the information concerning my right to make a lump sum deposit to the decedent's employing agency for
post-1956 military service.
If the deceased employee received military retired or retainer pay that was (1) not awarded because of a service-connected disability
incurred either in combat with an enemy of the United States or caused by an instrumentality of war and incurred in the line of duty during
a period of war or (2) awarded under reserve retiree provisions (chapter 1223 of title 10, United States Code), you will receive credit for
the military service subject to the rules for post-1956 military deposits. However, if you do receive credit for military service (including
any pre-1957 military service), your CSRS survivor benefit must be reduced by the amount of any military survivor benefits payable to
you. In some instances, it may be advantageous to receive a survivor benefit including the military service in the computation. In order to
advise you about the survivor annuity benefits, we need to know if you are eligible for military survivor benefits. Your documentation or
verification of your entitlement to military survivor benefits should be attached as indicated.
Survivor Election To exclude military service from the computation of your survivor annuity, check the box below.
Signature Date (mm/dd/yyyy)
NoYesYes complete item 4a
Standard Form 2800A
The December 2008 edition is usable.
6
Revised March 2012
$0.00
7
Section 3 - Agency Information and Certification
2a. Compensation claim number
3d. Compensation claim number
3b. Has a claim for workers' compensation
based on this death been filed?
3a. Did the above employee's death occur due to a work-related injury or illness?
1b. Does a survivor appear eligible for a monthly annuity?
1. Was the deceased employee enrolled in the Federal Employees Health Benefits Program?
2. If the deceased employee applied for workers' compensation (other than as listed in item 1a above) but did not receive benefits, check
reason below and give the requested information.
2c. What life insurance options did the deceased carry?
Name of deceased employee (last, first, middle initial) Date of birth (mm/dd/yyyy) Social Security Number
A. Employing Office: To be completed by office maintaining Official Personnel Folder (OPF)
Part 1 - General Information
Type of death benefit which appears payable
Monthly survivor annuity
Payment of retirement contributions
Part 3 - Federal Employees Health Benefits and Group Life Insurance Information
1. Did the deceased employee ever apply for or receive benefits from the Office of Workers' Compensation Programs (OWCP),
Department of Labor, because of a job-related illness or injury?
1a. Compensation claim number
Part 2 - Federal Employee's Compensation Information
3. Except for scheduled compensation awards, workers' compensation survivor benefits and survivor annuity benefits cannot be paid for
the same period of time. Please complete information below.
1b. Benefit received
1c. Type of benefit
From To
Scheduled award
Total or partial disability
Scheduled award Total or partial disability
No, go to item 3 below Yes, complete 1a - 3 below
Awaiting OWCP Claim denied
Yes, complete 3b-e below No, go to Part 3
3c. Name of person filing for workers' compensation
No, go to Part 3
Yes
Awaiting OWCP decision
Claim denied
3e. Date claim denied (mm/dd/yyyy)
Yes, complete 1a-b below
No, go to item 2
2. Did the deceased employee have Federal Employees' Group Life Insurance coverage?
Yes, go to item 2a-2c No, go to Part 4
1a. Enrollment code
Yes No
2b. What was the amount of basic annual pay certified?
Option A
Option B Option C
No optional coverage(s)
2b. Date claim denied
2a. When was the life insurance certified to the Office of
Federal Employees' Group Life Insurance (OFEGLI)? ____/____/_______
$
Standard Form 2800A
The December 2008 edition is usable.
7
Revised March 2012
3. If a former spouse of the deceased employee was making direct health benefit premium payments to your payroll office, has the SF
2806 been properly annotated?
2. Is deceased employee's health benefits status posted on SF 2806?
5. Disposition of SF 2806 SF 2807 number Date of SF 2807 Forwarded to:
4. Has the SF 2806 been properly annotated concerning deposit for post-1956 military service?
1. If deceased employee worked an irregular tour of duty (or exceeded his/her regular, part-time tour), are earnings for last 52 weeks
shown?
Form
Number
Part 4 - Checklist
Document Title Remarks
Sent to
OWCP
Attached
Yes No
None Children's birth certificates
Recommended for all children who are applying
for a monthly benefit
Part 5 - Certification by Personnel Officer (or Designee)
I certify that the above accurately reflects verified information in official records.
3. Address1. Signature
4. Official title
2. Date (mm/dd/yyyy)
5. Telephone number
B - Payroll Office Checklist
Yes No, explain in item 6.
Yes No, explain in item 6.
No, explain in item 6. Yes
No, explain in item 6.
Yes
Not applicable
SF 2806 and SF 2807
are attached
SF 2806 was mailed
6. Remarks
Certification by Payroll Officer (or Designee)
I certify that the above accurately reflects official records maintained by this office.
SF 2800 Application for Death Benefits
Required in all cases
SF 2809's
SF 2810's
DD 214
SF 2800A
Section 1
Health Benefits Election Form
Notice of Change in Health Benefits Enrollment
Military Discharge
Certified Summary of Federal Service
Required in all cases
Required in all cases, unless not covered under
FEHB plan
Recommended in all cases with military service
Required in all cases
SF 2800A
Section 2
Surviving Spouse's Military Deposit Election
Required in all cases with military service after
12/31/56 for which employee did not complete
deposit and a survivor annuity is payable
None Death certificate
Required in all cases
None Marriage certificate
Required for all married employees
None
None
None
Medical documentation (disabled children)
Adoption papers
Guardianship papers
Required for all disabled children
Required if applicant is an adopted child
Required if there is a court-appointed guardian for
eligible children or incompetent adult
None
Court appointment documents for executor/
administrator of estate
Required if there is a court-appointed fiduciary
and no monthly annuity is payable
None Social Security Number(s) for all applicants Required in all cases
6. Person to contact for further information (print or type)
7. Signature
10. Official title
12. Person to contact for further information (print or type)
9. Address
11. Telephone number
8. Date (mm/dd/yyyy)
Standard Form 2800A
The December 2008 edition is usable.
8
Revised March 2012
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