4.1 Certification of Status for Death Benefit - Standard Cal

ATTACHMENT 1 OMB Number: 0915-0334

Expiration date: (9/30/2016)

Countermeasures Injury Compensation Program (CICP)

Certification of Status for Death Benefit – Standard Calculation

Case Number: _______________________

This Certification will assist the Countermeasures Injury Compensation Program (CICP) in determining benefits. Please complete the statement below that applies to your case, and print and sign your name below. Please read all options before making a selection(s).

If a dependent has more than one legal guardian, only one guardian must complete and sign this form. If there are multiple dependents, a separate Certification must be completed and signed for each dependent by one guardian.

Option 1

I certify that __________________________________________________________

(deceased injured countermeasure recipient’s name)

did not receive a disability or death benefit under the Public Safety Officers’ Benefit (PSOB)

Program.

Option 2

I certify that __________________________________________________________

(deceased injured countermeasure recipient’s name)

did receive a disability or death benefit under the PSOB Program.

___________________________________________________________________________

(Please explain why deceased injured countermeasure recipient was covered under the PSOB Program.)

Option 3

I certify that __________________________________________________________ (deceased injured countermeasure recipient’s name)

was covered under the PSOB Program and no benefit was or will be provided.

Under the PSOB Program, the survivors of the deceased injured countermeasure recipient are eligible for a death benefit? ◻ Yes ◻ No

If yes, has it been paid yet? ◻ Yes ◻ No

If yes, how much has been paid? _________________________

I am the legal guardian of a dependent less than age 18 of the deceased injured countermeasure recipient who is eligible for death benefits from the Countermeasures Injury Compensation Program. By signing this form, I hereby certify that I have read the information provided about the standard calculation and the alternative calculation and have chosen to receive the death benefit under the standard calculation in place of the alternative calculation.

By signing this form, I hereby certify that the information provided in this Certification is true and accurate to the best of my knowledge. Further, I understand that false statements or claims made in connection with this Certification, including subsequent information and documentation submitted in connection with this Certification, may result in any remedy, including civil remedies, available by law to the United States. I will provide updated information (including, but not limited to medical records, employment income records, and change of address) until the Program has made its final benefits decision.

______________________________ _______________________________

Name of Legal Guardian (Please print) Name of dependent (if applicable)

______________________________ ___________________

Signature of Legal Guardian Date

OR

______________________________ _______________________________

Name of Requester (Please print) Name of Representative (if applicable)

______________________________ ___________________

Signature of Requester or Representative Date

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