Application for Death Benefits (FERS)/Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)
ICR 201509-3206-001 · OMB 3206-0172 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 3206-0172 can be found here:
Application for Death Benefits (FERS)/Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)
This collection is approved based on the revised materials provided by the Agency.
Inventory as of this Action
Requested
Previously Approved
03/31/2019
36 Months From Approved
03/31/2016
16,751
0
16,751
16,751
0
16,751
0
0
0
SF 3104, Application for Death Benefits (FERS), is used by persons applying for death benefits which may be payable under FERS because of the death of an employee, former employee, or retiree who was covered by FERS at the time of his/her death or separation from Federal Service. SF 3104B, Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death, is used by applicants for death benefits under FERS if the deceased was a Federal employee at the time of death.
Note: The SF 3104 has been revised to bring the form up-to-date. The following revisions are highlighted in the document:
Section F - Added a field for the Social Security Number.Â
US Code:
5 USC Chapter 84
Name of Law: Federal Employees Retirement System
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form SF 3104B Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death
SF3104_2015_10_MarkUp.pdf
SF3104_OMB_SuppStmt_2016_02_23.doc
Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death