Claim For Death Benefits Form - Public Safety Officers' Benefits Page 2

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PART II CONTINUED

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

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

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

Please attach a separate sheet of paper if there are additional children.

STATEMENTS AND CLAIM: All claimants are required to complete this Part. The purpose of this claim is to establish survivorship

eligibility and assert the rights to benefits under the Omnibus Crime Control and Safe Streets Act of 1968, as amended (42. U.S.C. 3796). The

filing of this claim does not constitute a determination by the Department of Justice that benefits will or will not be awarded to the claimant(s).

PART III

This claim may be prepared by a person acting on behalf of the claimant(s) such as a parent, legally appointed guardian, other legal

representatives, or duly designated representatives of the claimant(s). Evidence of authority to represent claimant(s) should be attached.

A. STATEMENT ON OTHER CLAIMS FILED WITH THE UNITED STATES GOVERNMENT AND/OR THE DISTRICT OF COLUMBIA:

Has claim been filed for benefits under

(1) Federal Employees Compensation Act, Section 8191 title 5, U.S. Code?

YES

(2) D.C. Retirement and Disability Act of September 1, 1916, Section 4-622?

YES

B. STATEMENT OF FINANCIAL NEED: If an immediate financial hardship has been incurred as a result of this death, an interim payment of $3000 may be made.

If you are experiencing an immediate financial hardship, please attach a statement of financial circumstances and need. This statement must include all financial

responsibility, all benefits that you are eligible for, and the benefits that you have received to date. If all documents required to complete this claim are received an

interim payment may not be necessary.

This form will be used by the Department of Justice to determine eligibility of a claimant for paying death benefits. The information may be disclosed to Federal, State,

and local agencies to verify eligibility for benefits. We must have Social Security Numbers to process payments.

I certify that the above information is correct and complete to the best of my knowledge. I certify further that I am not aware of any potential claimant for this PSOB

death benefit other than those listed above. I know of no facts or circumstances that would render the above-listed persons ineligible for this benefit. I understand that

a false or incomplete statement or a failure to fully disclose pertinent information concerning this claim may be grounds for non-payment of benefits or for prosecution

for a false statement under 18 U.S.C. § 1001.

All the information you give will be considered in reviewing the claim and is subject to investigation.

DATE

SIGNATURE OF CLAIM ANT OR AUTHORIZED REPRESENTATIVE

(If representative, provide claimant’s affidavit granting pow er of attorney)

E-MAIL (If available)

Home number. (Including Area Code)

Work number (Including Area Code)

Alternate number (Including Area Code)

Public Reporting Burden

Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid

Paper Reduction Act Notice.

OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and that impose the least possible burden on you to provide

us with information. The estimated average time to complete and file this application is 90 minutes per application. If you have comments regarding the accuracy of

this claim, or suggestions for making this claim form simpler, you can write to the Public Safety Officers’ Benefits Program, Bureau of Justice Assistance, 810 7

Street, NW, Washington, D.C. 20531 and to the Office of Information and Regulatory Affairs, Office or Management and Budget, Washington, D.C. 20530.