OMB No. 0704-0367
OMB approval expires
INVOLUNTARY ALLOTMENT APPLICATION
Nov 30, 2010
The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(0704-0367). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not
display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. SEND YOUR COMPLETED FORM TO THE ADDRESS IN THE
INSTRUCTIONS BELOW.
INSTRUCTIONS
1. These instructions govern an application for involuntary allotment payment from Military Service (or Coast Guard) member's active or
reserve/guard's pay under 5 USC Section 5520a.
2. In order to be processed, this form must be filled out completely, signed, and the following supporting documents attached:
a. A copy of the judgment, certified by the clerk of the appropriate court;
b. If the applicant is other than the original judgment holder, proof of the applicant's right to succeed to the interest of the original
judgment holder.
3. Submit the original and two copies of this application and all supporting documents to:
For Army, Navy, Air Force and Marine Corps:
For Coast Guard:
Defense Finance and Accounting Service
Commanding Officer
Cleveland Center, Code GAG
U.S. Coast Guard
PO Box 998002
Personnel Service Center (LGL)
Cleveland, OH 44199-8002
444 S.E. Quincy Street
Topeka, KS 66683-3591
SECTION I - IDENTIFICATION
1. APPLICANT
I hereby request that an involuntary allotment be established from the pay of the following identified member of the Military Services/ Coast
Guard pursuant to the provisions of Pub. L. No. 103-94, the Hatch Act Reform Amendments of 1993. The debt in question has been reduced to
a judgment. A copy of the judgment, as certified by the appropriate Clerk of Court, is attached.
a. APPLICANT NAME (Provide whole name whether a person or business)
b. TELEPHONE NUMBER (Incl. Area Code)
c. ADDRESS
(1) STREET AND APARTMENT OR SUITE NUMBER
(2) CITY
(3) STATE
(4) ZIP CODE (9 digit)
2. SERVICE MEMBER
a. NAME (Last, First, Middle Initial)
b. SSN
c. BRANCH OF SERVICE
d. CURRENT DUTY ASSIGNMENT (If known)
e. CURRENT ADDRESS (If known)
(1) STREET AND APARTMENT OR SUITE NUMBER
(2) CITY
(3) STATE
(4) ZIP CODE (9 digit)
3. CASE
a. CASE NUMBER (As assigned
b. NAME OF ORIGINAL JUDGMENT HOLDER
c. ACCOUNT NUMBER OF DEBTOR
by court)
(If different from applicant)
d. JUDGMENT AMOUNT
(2) DOLLAR AMOUNT OF INTEREST OWED TO DATE
(1) DOLLAR AMOUNT OF JUDGMENT
(3) TOTAL DOLLAR AMOUNT DUE
OF APPLICATION
(Total of sub-blocks (1) and (2))
0.00
$
$
$
Reset
DD FORM 2653, NOV 2007
PREVIOUS EDITION IS OBSOLETE.
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