Form 3650/6 Report of Public safety Officer's Death

APPROVED: OMB NO. 1121-0025
EXPIRES: 04/30/2007
U.S. DEPARTMENT OF JUSTICE
OFFICE OF JUSTICE PROGRAMS
BUREAU OF JUSTICE ASSISTANCE
PUBLIC SAFETY OFFICERS BENEFITS PROGRAM
WASHINGTON, D.C. 20531

FOR DOJ USE ONLY
CASE NUMBER
DATE RECEIVED

REPORT OF PUBLIC SAFETY OFFICER’S DEATH

This information is being requested pursuant to the Omnibus Crime Control and Safe Streets Act of 1968, as amended (42 U.S.C. 3796), and the disclosure is
voluntary. This form will be used by the Department of Justice to determine eligibility of a claimant for the payment of benefit and the information may be disclosed to
Federal, State and local agencies to verify eligibility for benefits. Disclosure of an individual’s Social Security number is mandatory. Failure to supply requested
information may result in a delay in processing this form and receipt of benefits. PLEASE PRINT CLEARLY 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)

PART I: NOTICE OF LINE OF DUTY DEATH OF PUBLIC SAFETY OFFICER
7. AT THE TIME OF INJURY THAT RESULTED IN DEATH WAS THE OFFICER WORKING A
REGULAR SHIFT OR AN ASSIGNED OVERTIME SHIFT?
YES 9
NO 9

8. OFFICER’S EMPLOYMENT STATUS
WHEN INJURY OCCURRED.

IF NO, ATTACH AN AFFIDAVIT EXPLAINING THE OFFICER’S DUTY STATUS.

FU LL-TIM E

9

PAR T-TIM E

9

V O LU N TEER

9

O THER

9

AS A

IN THE SERVICE OF

PAR O LE O FFIC ER

9
9
9
9

FIR E FIG HTER

9

JU D IC IAL OFFIC ER

9

LAW EN FO R C EM EN T
C O R REC TIO N S O FFIC ER
PR O BATIO N O FFIC ER

AM BU LAN C E AN D R ESCU E
SQ U AD M EM BER
O THER

(Specify)

9.

9
9

FED ER AL GO V ER N M EN T

9
9
9

LEG ALLY O R G AN IZED V O LU N TEER FIR E,
AM BU LAN C E O R R ESC U E SQ U AD , D EPAR TM EN T
O RG ANIZED , CHAR TED O R FO RM E D BY A
PU BLIC AG EN C Y TO AC T O N ITS B EHALF
IN PR O V ID IN G FIR E O R R ESCU E SERV IC ES
TO THE PU BLIC

9

O THER

9

STATE G O V ER N M EN T
LO C AL UN IT O F G O V ER N M EN T

(Specify)

WAS INJURY CONTRIBUTED BY:
OFFICER’S GROSS NEGLIGENCE?
OFFICER’S INTENTIONAL MISCONDUCT?
OFFICER’S INTENT TO BRING ABOUT HIS OWN DEATH?
OFFICER’S VOLUNTARY INTOXICATION?
ANY PERSON WHO MAY BE ENTITLED TO BENEFIT?

YES
9
9
9
9
9

NO
9
9
9
9
9

UNKNOWN
9
9
9
9
9

(Attach explanations for any “yes” answer.)

PART II: INFORMATION CONCERNING POSSIBLE CLAIMANTS: Provision of this information does not constitute a finding for or against
an interim Payment of Benefits or Final Award of Benefits. If the officer was not married at the time of his death, but was cohabiting with another
person in what could be construed as a common-law marriage, please indicate that relationship below.
10. NAMES, RELATIONSHIP, AND ADDRESS OF PERSONS IN PRECEDENCE ORDER AND APPLICABILITY CATEGORY AS FOLLOW S:

SURVIVING SPOUSE OR COHABITANT
NAME (Last, First, Middle)

MAILING ADDRESS (Include zip code)

SOCIAL SECURITY NO.

PART II CONTINUED
CHILDREN:
NATURAL, ADOPTED, STEPCHILDREN,
POSTHUMOUS, OUT OF WEDLOCK,
REGARDLESS OF AGE OR DEPENDENCY STATUS
10a. NAME (Last, First, Middle)

DATE OF BIRTH

SOCIAL SECURITY NO.

Marital status regardless of age
Married

9

Single

9

Address (if different from item 11, above) and Telephone Number

PARENT OR LEGAL GUARDIAN NAME & SOCIAL SECURITY NUMBER

10a. NAME (Last, First, Middle)

SOCIAL SECURITY NO.

DATE OF BIRTH

Marital status regardless of age
Married

9

Single

9

PARENT OR LEGAL GUARDIAN NAME & SOCIAL SECURITY NUMBER

Address (if different from item 11, above) and Telephone Number

Please attach a separate sheet of paper if there are additional children.
10.b IF THE DECEDENT IS SURVIVED BY NEITHER SPOUSE NOR ELIGIBLE CHILDREN, PROVIDE A COPY OF THE
OFFICER'S MOST RECENT DEPARTMENTAL LIFE INSURANCE POLICIES, INCLUDING BENEFICIARY DESIGNATION PAGE.
PLEASE NOTE: The decedent’s family will be asked to provide the most recent private insurance policies.

BENEFICIARIES:
NAME (Last, First, Middle)

SOCIAL SECURITY NO.

MAILING ADDRESS (Include zip code)

NAME (Last, First, Middle)

SOCIAL SECURITY NO.

MAILING ADDRESS (Include zip code)

PART III: INFORMATION CONCERNING OTHER CLAIMS
11. TO YOUR KNOWLEDGE HAS OR WILL A CLAIM BE FILED FOR BENEFITS UNDER:
A) Federal Employees Compensation Act, Section 8191 title 5, U.S. Code?
YES 9 NO 9
B) D.C. Retirement and Disability Act of September 1, 1916, Section 4-622?
YES 9 NO 9
PART IV: CERTIFICATION A false answer to any question in this Statement may be grounds for non-payment of benefits and may be punishable by fine or
imprisonment (U.S. Code, Title 18, Sec. 1001). All the information you give will be considered in reviewing the claim and is subject to investigation.
12. EMPLOYING ORGANIZATION - To the best of my knowledge and belief, the above stated information is true and complete.
ORGANIZATION

ADDRESS (Include zip code)

TYPED NAME & TITLE OF EMPLOYING AGENCY HEAD

PHONE NO.

E-MAIL ADDRESS

SIGNATURE OF EMPLOYING AGENCY HEAD

DATE

1 3. IS THERE A RETIREMENT/DISABILITY BOARD, WORKERS COMPENSATION BOARD, COURT, OR OTHER ENTITY THAT WILL CONSIDER OR HAS BEEN
CONSIDERED THE FACTS OF THIS CASE IN ORDER TO DETERMINE ELIGIBILITY FOR OTHER BENEFITS?
YES 9
NO 9

14. WAS A FAVORABLE DECISION RENDERED?

YES 9

NO 9

If “yes,” on a separate sheet of paper please give address and telephone number for each entity.
Public Reporting Burden
Paper Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid 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 2½ hours 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 7th Street, NW, Washington,
D.C. 20531 and to the Office of Information and Regulatory Affairs, Office or Management and Budget, Washington, D.C. 20530.