DEATH GRATUITY PAYMENT FUNDING AUTHORIZATION SHEET
1.
Deceased Employee/Auxiliarist Name:
Last: __________________________ First: _____________________ MI: _________
2.
Date of Death: _______/_______/_______
3.
Personal Representative's Name, Mailing Address, and Telephone number:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4.
Office of Workers' Compensation Program (OWCP) Approval (check one):
Case Number: _____________________
Approved
Approved Other (explain below)
Disapproved
Not Filed with OWCP
Comments: ___________________________________________________
_____________________________________________________________
_____________________________________________________________
5.
Authorizing Signature (check one):
Civilian (G-WPC-3)
Auxiliary (G-OCX)
_________________________________________Date: __________________
6.
Amount of Gratuity Payment and Date Sent:
_________________________________________Date: __________________
7.
Funding approval (G-WR):
_________________________________________Date: __________________
Department of Homeland Security, CG-6023 (04-03)