Get Form Omb No 1121 0025 2014-2025

Filling out the Form Omb No 1121 0025 online can be a straightforward process if you follow the instructions carefully. This guide provides step-by-step guidance on completing the form to report a public safety officer's death efficiently and accurately.

Follow the steps to complete the Form Omb No 1121 0025 online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by carefully entering the officer's information, including their full name, title, social security number, and dates of injury and death in the relevant fields.
3. Fill out the employing agency information, providing the full name and physical address of the agency where the officer served.
4. In Part I, indicate whether the officer was working a regular or assigned overtime shift at the time of the injury, and select their employment status.
5. Answer questions about any contributing factors to the injury that resulted in death; if you select 'yes' for any, ensure you attach an explanation.
6. Proceed to Part II, where you will enter information regarding possible claimants, including the name and relationship of the surviving spouse or children.
7. If necessary, follow the instructions to submit information about life insurance policies if the officer is survived by neither spouse nor applicable children.
8. In Part III, confirm whether any claims have been filed for benefits under other acts, and provide details if applicable.
9. Finally, complete Part IV, certify that the information is accurate, and make sure to include the signature of the employing agency head.
10. Once you have filled out the entire form, save your changes, and download, print, or share the completed form as necessary.

Complete your documentation online today to ensure a smooth filing process.