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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

Form approved: OMB No. 3206-0156

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. Information and Elections Regarding Post-1956 Military Service To be completed by applicant, if appropriate. Agency Information and Certification To be completed by deceased person's employing agency's personnel and payroll offices.

Section 2: Section 3:

Privacy Act Statement Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 84, 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 think 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, OPM Forms Officer (3206-0156), Washington, D.C. 20415-7900. 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.

Office of Personnel Management 5 CFR 831

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Standard Form 2800A Revised June 2006 Previous editions are not 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. 2. Name of employee (last, first, middle initial) List all other names used (maiden name, AKA, spelling variants) 3. 5. 7. Date of birth (mm/dd/yyyy) Other birth dates used 4. Social Security Number 6. Military serial number

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.


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Standard Form 2800A Revised June 2006

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 Total From To earned

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 Date Agency name and address, including ZIP code Official title Telephone no. & area code

Part E - Applicant's Certification
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. Signature (do not print) Date

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Standard Form 2800A Revised June 2006

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. 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.

b.

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.

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Standard Form 2800A Revised June 2006

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. 2. The amount of deposit is 7 percent of military basic pay (plus interest, if any). 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. 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.

2.

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. 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. In order to credit your deposit, OPM must receive documentation of your payment from the agency before your application is completely adjudicated. 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.

2.

3.

4.

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Standard Form 2800A Revised June 2006

SURVIVOR'S MILITARY SERVICE ELECTION Deceased Employee Covered by CSRS or CSRS Offset Part A - To be completed by employing agency
1. 4. Employee's name (last, first, middle initial) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number Is survivor eligible for an annuity based on the minimum basic annuity? 4a. If item 4 is "yes," would loss of credit for post-1956 military service reduce the amount of the annuity? Annuity will be based complete item 4a No on actual service Yes Yes No Was a deposit account opened for the employee? Period of Military Service To No Yes complete information below Amount due (with interest) Amount paid by employee Balance due
$0.00

5.

From 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. before October 1, 1982 on or after October 1, 1982 Agency representative to contact for information Agency personnel office address to which form should be returned Telephone number Election must be received by date (mm/dd/yyyy)

7. 8.

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. 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. I elect not to make (or complete) the deposit for post-1956 I elect to make (or complete) the deposit to the employing military service. I understand this decision is irrevocable after agency for the decedent's post-1956 military service. I OPM completes the processing of my application for survivor understand that this deposit must be paid to the agency in a lump sum. (Note:The election may be changed at any time benefits. before the deposit is actually paid to the agency.)

Part C - To be completed by survivor of deceased employee in receipt of military retired pay at the time of death
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. I have attached verification of my eligibility or ineligibility for military survivor benefits. .) (Specify monthly amount, if known $ Survivor Election To exclude military service from the computation of your survivor annuity, check the box below. I elect to exclude the decedent's military service from my survivor annuity. Signature Date (mm/dd/yyyy)

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Standard Form 2800A Revised June 2006

Section 3 - Agency Information and Certification
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 2 - Federal Employee's Compensation 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? Yes, complete 1a - 3 below 1b. Benefit received From To No, go to item 3 below 1c. Type of benefit Scheduled award Scheduled award 2. Total or partial disability Total or partial disability

1a. Compensation claim number

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.

2a. Compensation claim number

2b. Date claim denied Awaiting OWCP Claim denied 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. 3a. Did the above employee's death occur due to a work-related injury or illness? Yes, complete 3b-e below No, go to Part 3 3b. Has a claim for workers' compensation 3c. Name of person filing for workers' compensation No, go to Part 3 based on this death been filed? Yes 3d. Compensation claim number Awaiting OWCP decision 3e. Date claim denied (mm/dd/yyyy) Claim denied

Part 3 - Federal Employees Health Benefits and Group Life Insurance Information
1. Was the deceased employee enrolled in the Federal Employees Health Benefits Program? Yes, complete 1a-b below No, go to item 2 1b. Does a survivor appear eligible for a monthly annuity? 1a. Enrollment code Yes No 2. Did the deceased employee have Federal Employees' Group Life Insurance coverage? Yes, go to item 2a-2c No, go to Part 4 2a. When was the life insurance certified to the Office of 2b. What was the amount of basic annual pay certified? Federal Employees' Group Life Insurance (OFEGLI)? ____/____/_______ $ 2c. What life insurance options did the deceased carry?
Option A Option B Option C No optional coverage(s)

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Standard Form 2800A Revised June 2006

Part 4 - Checklist
Form Number SF 2800 SF 2809's SF 2810's DD 214 SF 2800A Section 1 SF 2800A Section 2 None None None None None None None None Document Title Application for Death Benefits Health Benefits Election Form Notice of Change in Health Benefits Enrollment Military Discharge Certified Summary of Federal Service Surviving Spouse's Military Deposit Election Remarks Required in all cases 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 Required in all cases with military service after 12/31/56 for which employee did not complete deposit and a survivor annuity is payable Required in all cases Required for all married employees Recommended for all children who are applying for a monthly benefit 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 Required if there is a court-appointed fiduciary and no monthly annuity is payable Required in all cases
Attached

Yes

No

Sent to OWCP

Death certificate Marriage certificate Children's birth certificates Medical documentation (disabled children) Adoption papers Guardianship papers Court appointment documents for executor/ administrator of estate Social Security Number(s) for all applicants

1. 4. 6.

Signature Official title

I certify that the above accurately reflects verified information in official records. 2. Date (mm/dd/yyyy) 3. Address 5. Telephone number

Part 5 - Certification by Personnel Officer (or Designee)

Person to contact for further information (print or type)

B - Payroll Office Checklist
1. 2. 3. 4. 5. If deceased employee worked an irregular tour of duty (or exceeded his/her regular, part-time tour), are earnings for last 52 weeks shown? Yes No, explain in item 6. Yes No, explain in item 6. 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? Not applicable Yes No, explain in item 6. Has the SF 2806 been properly annotated concerning deposit for post-1956 military service? Yes Disposition of SF 2806 Forwarded to: SF 2807 number Date of SF 2807 SF 2806 and SF 2807 are attached SF 2806 was mailed Remarks No, explain in item 6. Is deceased employee's health benefits status posted on SF 2806?

6.

7.

Signature

I certify that the above accurately reflects official records maintained by this office. 8. Date (mm/dd/yyyy) 9. Address 11. Telephone number

Certification by Payroll Officer (or Designee)

10. Official title

12. Person to contact for further information (print or type)

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Standard Form 2800A Revised June 2006