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 202203-3206-009 · OMB 3206-0172 · Received in OIRA
⚠️ Notice: This information collection may be outdated.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)
No material or nonsubstantive change to a currently approved collection
No
Regular
03/08/2022
Requested
Previously Approved
11/30/2022
11/30/2022
16,751
16,751
16,751
16,751
225,066
225,066
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.
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 Standard Form 3104 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
OMB_Justification_SF3104B_2022_03_08.docx
FACES 2017 FINAL 12212017signed.pdf
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