Approved OMB No. 1121-0024 (Expires: 04/30/2007)
U.S. DEPARTMENT OF JUSTICE
FOR DOJ USE ONLY
OFFICE OF JUSTICE PROGRAMS
BUREAU OF JUSTICE ASSISTANCE
CASE NUMBER
PUBLIC SAFETY OFFICERS BENEFITS PROGRAM
WASHINGTON, D.C. 20531
DATE RECEIVED
CLAIM FOR DEATH BENEFITS
This form should be filed by a surviving spouse, child/children, insurance beneficiary and/or parent(s) of the deceased public safety officer. This claim may be prepared
by someone on behalf of these individuals. If you are filing on behalf of others, you must attach evidence of your authority to do so.
PLEASE PRINT PLAINLY OR TYPE
1. NAME OF OFFICER (Last, First, Middle)
2. OFFICER’S TITLE
3. SOCIAL SECURITY NUMBER
4. DATE OF INJURY
5. DATE OF DEATH
6. NAME AND PHYSICAL ADDRESS OF EMPLOYING AGENCY, ORGANIZATION OR UNIT IN WHOSE SERVICE DEATH OCCURRED (Include zip code)
INSTRUCTIONS: T
o ensure payment to all eligible individuals, attach valid documentation (such as notarized, certified, or attested to documentation) regarding
marriage, divorce, separation decrees, death certificates, birth certificates, adoption papers, custody agreements, or other evidence of parent-child relationship, as appropriate
for any claimant in Parts I and II
If at the time of an officer’s death the officer was survived by a husband, wife, or parent(s), Part I should be completed. If there are children of the
PART I
INFORMATION
officer, regardless of age or dependency, Part II must be completed. (Attach certified copies of marriage license, all divorce decrees (including
ON SURVIVING
custody agreements), or separation agreements as applicable to martial relationship with the officer and certified copies of children’s birth
BENEFICIARY
certificates.) If the decedent is survived by neither spouse nor eligible child, provide a copy of the officer's most recent life insurance policies.
PLEASE NOTE: The decedent’s employing agency will be asked to provide departmental insurance policies.
7. ELIGIBLE BENEFICIARY
Spouse
Mother
Father
Other beneficiary
NAME (Last, First, Middle)
SOCIAL SECURITY NO.
MAILING ADDRESS (Include zip code)
NAME (Last, First, Middle)
SOCIAL SECURITY NO.
MAILING ADDRESS (Include zip code)
9. DO YOU HAVE REASON TO BELIEVE THAT THE
10. DO YOU HAVE REASON TO BELIEVE THAT
8. MARITAL STATUS OF OFFICER AT TIME OF
OFFICER WAS MARRIED AT ANY TIME TO
THE OFFICER HAD A CHILD(REN) FROM A
DEATH.
ANYONE ELSE?
PREVIOUS MARRIAGE OR RELATIONSHIP?
YES
NO
UNKNOWN
MARRIED
SINGLE
YES
NO
If yes, please list number of m arriages and submit documents
SEPARATED
OTHER
________________
to show dissolutio n of prior marriages, such as death
If yes, include in Part II or explain on a separate sheet of
DIVORCED
(Please identify)
certificates or divorce decrees. ________________
paper and attach to this form.
9a.
Attach necessary documentation such as marriage certificates, all
List number of times surviving spouse w as previously
divorce decrees and custody agreements, or separation agreements.
married. _____________
PART II
SURVIVING
If the officer was survived by a natural, out-of-wedlock, adopted or posthumous child, or stepchild (or children) at the time of death, complete this
CHILDREN
part. All surviving children should be listed regardless of age or dependency status at the time of the officer’s death. Attach a certified copy of birth
INFORMATION
certificates, adoption papers, DNA results, or other evidence of parent-child relation, as appropriate.
If over 18, educational status at
11. NAME (Last, First, Middle Initial)
Date of Birth
Social Security No.
the time of parent’s death
Marital Status regardless of age
Full-Time
Part-Time
N/A
Married
Single
Address (if different from item 7, above) and Telephone Number
PARENT OR LEGAL GUARDIAN NAME & SOCIAL SECURITY NUMBER