Ps Form 6510 - Death Gratuity Payment Authorization - United States Postal Service

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Death Gratuity Payment Authorization
Part A: Purpose
This form is to be used for payment for an employee’s death due to an injury sustained in the line of duty, as stated under
Management Instruction (MI) FM-640-2015-2, Payment of Death Gratuity.
Part B: Deceased Employee Information
Instructions: This section is to be filled out by the area vice president (AVP) or appropriate Headquarters (HQ) vice president.
Deceased Employee’s Name (Last, First, MI): _______________________________________________________________________
Date of Birth: ______/______/_______
Employee Identification Number: _______________________
Date of Death: ______/______/_______
Finance Number: _____________________________________
Date of Injury: ______/______/_______
Provide a brief description of the injury that resulted in the employee’s death:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Postal Service Representative:
Signature: __________________________________________
Date: ______/______/_______
Name: _____________________________________________
Part C: Personal Representative Information and Certification
Instructions: The Personal Representative must provide their name, mailing address, telephone number, and Social Security
number (SSN) or Estate Taxpayer Identification Number (EIN):
Name: ____________________________________________________________________
Mailing Address: ___________________________________________________________
___________________________________________________________
___________________________________________________________
Telephone Number: (
) __________ - _________________
SSN or EIN: ________ - ______ - ___________
I attest that I am the duly appointed Personal Representative of the Deceased Employee’s estate as defined in the law. I have
attached to this form legal documentation proving my status as Personal Representative.
As the Personal Representative for the Deceased Employee shown above, I am aware that this death gratuity payment
is a taxable event — for which I will receive a Form 1099-R in my capacity as personal representative of the Deceased
Employee’s estate.
I understand that the Postal Service may advance to me, on behalf of the Deceased Employee’s estate, a death gratuity
under MI FM-640-2015-2 on the condition that it be refunded to the Postal Service should the conditions for the death
gratuity not be satisfied. I certify that, before signing this form, I have been provided with a copy of MI FM-640-2015-2 which
explains the conditions that must be satisfied for receipt of the death gratuity, that I have been given the opportunity to ask
about them, and that I understand them. In my capacity as representative of the Deceased Employee’s estate, and on behalf
of the Deceased Employee’s estate: a) I understand and agree that the estate will refund the death gratuity paid pursuant to
MI FM-640-2015-2 if it is determined that the conditions for the death gratuity are not satisfied; and b) I agree to cooperate
with the Postal Service in its efforts to confirm that the conditions for the death gratuity have been satisfied.
In addition, if it is determined that I am not the Personal Representative of the Deceased Employee’s estate, I understand
and agree, in my individual capacity, that I will refund the death gratuity paid to me under MI FM-640-2015-2.
6510,
PS Form
January 2015

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