Fillable Dd Form 2653 - Involuntary Allotment Application Form (Page 2 of 2) in pdf

SECTION II - APPLICANT CERTIFICATION

4. I HEREBY CERTIFY THAT:

(X as applicable)

(1) The judgment has not been amended, superseded, set aside, or satisfied;

(2) If the judgment has been paid in part, the total amount remaining to be paid is $

(X as applicable)

(1) The judgment was issued while the member was not on active duty; or

(2) If the judgment was issued while the member was on active duty, that the member was present or

represented by an attorney of the member's choosing in the proceedings; or

(3) If the member was not present or represented by an attorney at the judicial proceedings, that the judgment

complies with the Servicemembers Civil Relief Act, 50 U.S.C. App. Sections 501-596 (2003). (If you obtained a

default judgment and it does not contain language that indicates that the plaintiff complied with 50 U.S.C. App.

501-593, then you must submit proof that an affidavit stating the member's military service status, as required by

50 U.S.C. App. 520, was filed with the court prior to entry of the judgment.)

c. The member's pay could be garnished under applicable State law and 5 USC 5520a if the member were a

civilian employee;

d. To the best of my knowledge, the debt has not been discharged in bankruptcy nor has the member filed for

protection from creditors under the bankruptcy laws of the United States;

e. I will promptly notify you to discontinue the involuntary allotment at any time the judgment is satisfied prior to

the collection of the total amount of the judgment through the involuntary allotment process;

f. If the member overpays the amount owed on the judgment, I will refund the amount of overpayment to the

member within 30 days of discovery or notice of the overpayment, whichever is earlier, and that if I fail to repay

the member, I understand that I may be denied the right to collect by involuntary allotment on other debts

reduced to judgments.

5. I HEREBY ACKNOWLEDGE THAT:

As a condition of application, I agree that neither the United States, nor any disbursing official or Federal employee

whose duties include processing involuntary allotment applications and payments, shall be liable with respect to any

payment or failure to make payment from moneys due or payable by the United States to any person pursuant to this

application.

6. CERTIFICATION

I make the foregoing statement as part of my application with full knowledge of the penalties involved for willfully

making a false statement (U.S. Code, Title 18, Section 1001, provides a penalty as follows: Shall be fined under this

title or imprisoned not more than 5 years, or both.

a. TYPED NAME (Last, First, Middle Initial)

b. TELEPHONE NO.

c. SIGNATURE

d. DATE SIGNED

(Include area code)

(YYYYMMDD)

Reset

DD FORM 2653 (BACK), NOV 2007

Dd Form 2653 - Involuntary Allotment Application Form Page 2