RI25-051_2011_05_MarkUp

Form Approved:
OMB Number 3206-0233

Civil Service Retirement System
Survivor Annuitant Express Pay
Application for Death Benefits

Civil Service
Retirement System

Your name (last, first, middle)
CSF case label
Email address

Are there unmarried disabled or dependent children of the deceased? If so, please list them. Please also provide the name, address, and
telephone number (if known) of the person who has custody and a date of birth and social security number for each child. If there are no such
children, please write "none." Continue on a separate sheet of paper if you need to list more than two.
Date of birth (mm/dd/yyyy)

Child's name

Social Security Number

Full-time student
Yes

No

Custodian's name, address, and telephone number

Child's name

Date of birth (mm/dd/yyyy)

Social Security Number

Full-time student
Yes

No

Custodian's name, address, and telephone number

The U.S. Department of the Treasury will pay all federal benefits electronically. Your payments should be made by Direct Deposit into your
checking or savings account or you need to arrange for a Direct Express debit card provided by the Department of the Treasury. For more
information see the instructions for using this application form.

I elect to receive payments by:
Direct Deposit based on the information shown below.

Direct Express debit card.

Name of financial institution

Telephone number (including area code)

EFT routing number

Account number (if applicable)

Address

Type of account
Checking

Savings

I live ouside the United States where Direct
Deposit and Direct Express are not available.
Your signature below certifies that you were married to the deceased and met the duration-of-marriage requirements (see instructions on the
reverse) at the time of his or her death, that your date of birth and your social security number are as shown below, and that you are not eligible
for survivor benefits based on the service of another former Federal employee. Please make corrections to your Social Security Number and date
of birth as necessary. Your signature below also certifies that information provided in this application is true to the best of your knowledge and
that no evidence necessary to the settlement of this claim has been withheld.

Signature

Telephone number (including area code)

Mailing address

Date of birth (mm/dd/yyyy)
Social Security Number

Warning:

Any intentionally false or willfully misleading statement or response you provide in this application is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of not more than five years or both. (18 USC 1001).

Previous editions are not usable.

(See Reverse for Instructions)

RI 25-51
Revised May 2011

U.S. Office of Personnel Management
Civil Service Retirement System
Retirement Operations Center
P.O. Box 45
Boyers, Pennsylvania 16017-0045

Instructions for Civil Service Retirement System
Survivor Annuitant Express Pay Application for Death Benefits
You cannot use this application if —
•

You were not married to the retiree when he or she died.

•

You are entitled to another survivor annuity under the Civil Service Retirement System or any other retirement
system for Government employees.

Complete each item on the application form and include a copy of the death certificate.
Return the application and death certificate in the enclosed envelope within 30 days or call us at 1-888-767-6738 if
you need additional time to apply.
Application from Current Spouse

You can use this form to apply for recurring monthly
survivor annuity payments if:

The U.S. Department of the Treasury will recover any
payments to the retiree deposited by Electronic Funds
Transfer after the retiree died.

•

Payments to You

•

you were married to the deceased at the time of his
or her death for at least nine months, and
your spouse elected to receive a reduced annuity to
provide you with a survivor benefit.

The nine month duration of marriage requirement does not
apply if your spouse’s death was accidental or you and the
deceased had a child.
Children’s Eligibility

Children born to the deceased and children the deceased
adopted are eligible for monthly survivor annuity payments
if:
•

they are not married and under age 18,

•

they are not married, are full-time students, and are
age 18 to age 22,

•

they are not married, age 18 or older, and OPM has
already determined that they are disabled.

Payments to the Deceased
Any checks the retiree failed to negotiate must be returned
to the U.S. Department of the Treasury. These checks are
not negotiable by law. The Office of Personnel
Management will authorize the lump-sum payment of any
monies due the retiree as soon as possible. The lump sum
will be paid to the person who is legally entitled to it.

We have already started payments to you. These
payments will be suspended after 60 days if we do not
receive your application or you do not contact us.
If your payment includes your annuity and the annuity for
your children, you are obligated to inform us if a child
marries or if a disabled child recovers from the disability.
Direct Deposit Program/Direct Express Debit Card

The Department of the Treasury is no longer issuing
paper checks to pay benefits to persons who live in the
United States or in places where Electronic Funds
Transfer [Direct Deposit/Direct Express] is available. To
enroll in the Direct Deposit program, contact us or
complete Standard Form 1199A, Direct Deposit Sign-Up
Form, which you can get at your financial institution. To
obtain a Direct Express card, go to www.godirect.org or
call the Department of the Treasury at 1-800-333-1795.

For More Information

If you have questions or believe you cannot use this form
to apply, call us at 1-888-767-6738. Use the address
shown at the top of this page if you need to write to us.

Privacy Act and Public Burden Statements
Title 5, U.S. Code, Chapter 83, authorizes the solicitation of this information. The data you furnish will be used to identify records properly associated with your
application; to obtain additional information, if necessary; to determine and allow present or future benefits; and to maintain a unique identifiable claim file. 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 as an individual identifier to distinguish between people with the same or similar names. Failure to furnish
information may result in suspension of your payments.
We estimate providing this information takes an average 30 minutes per response, including the time for reviewing instructions, getting the needed data, and
reviewing the requested information. Send comments regarding our estimate or any other aspect of this form including suggestions for reducing completion
time, to the U.S. Office of Personnel Management, Retirement and Benefits Publications Team (3206-0233), Washington D.C. 20415-3430. The OMB number
(3206-0233) is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Reverse of RI 25-51
Revised May 2011