Dd Form 2675, Reimbursement Request For Adoption
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3REIMBURSEMENT REQUEST FOR ADOPTION EXPENSES
(Please read Privacy Act Statement and Application Processing Instructions on page 3 before completing this form.)
SECTION I - MEMBER INFORMATION
1. NAME OF MEMBER (Last, First, Middle Initial) (Print or Type)
2. SSN
3. MARITAL STATUS (Check one)
a. SINGLE
b. MARRIED
c. DIVORCED
4. PAY GRADE
5. EXPIRATION OF SERVICE
6. HOME TELEPHONE NO.
7. WORK TELEPHONE NO.
8. CELL PHONE NO.
DATE (YYYYMMDD)
9. MEMBER'S BRANCH OF SERVICE (Must be in active duty status with 180 days of continuous service)
a. AIR FORCE
b. ARMY
c. MARINE CORPS
d. NAVY
10. CORRESPONDENCE ADDRESS (Include 9-digit ZIP Code and Apartment
11. EMAIL ADDRESS
number, if applicable)
12. ANY PREVIOUS REIMBURSEMENT
YES
CLAIMED FROM DOD IN CURRENT
CALENDAR YEAR (Check one)
NO
SECTION II - SPOUSE INFORMATION
13. IS SPOUSE A MEMBER OF THE ARMED FORCES (Including the U.S. Coast Guard) (Check one)
YES
NO
14. IF YES, NAME OF SPOUSE (Last, First, Middle Initial)
15. SSN OF SPOUSE
16. BRANCH OF SERVICE OF SPOUSE
a. AIR FORCE
b. ARMY
c. MARINE CORPS
d. NAVY
e. COAST GUARD
SECTION III - ELECTRONIC FUND TRANSFER INFORMATION
(RTN must be provided.)
17. ROUTING TRANSIT NUMBER
18. ACCOUNT NUMBER
19. ACCOUNT TYPE (Check one)
CHECKING
SAVINGS
20a. INSTITUTION NAME
20b. MAILING ADDRESS OF INSTITUTE (Include 9-digit ZIP
Code)
SECTION IV - ADOPTION INFORMATION
21. DATE OF HOME STUDY
22. DATE CHILD PLACED
23. DATE ADOPTION FINALIZED
24. STATE OR COUNTRY WHERE THE
(YYYYMMDD)
IN HOME (YYYYMMDD)
(YYYYMMDD)
ADOPTION WAS FINALIZED
25. NOTES:
a. Members on nonactive duty or members on active duty less than 180 days are not eligible for adoption reimbursement.
b. Reimbursement of adoption expenses may be paid only after the adoption is final. Members who leave active duty before the
final adoption decree is granted are not entitled to reimbursement.
c. Reimbursement claims must be submitted no later than 365 days after adoption is finalized. Failure to do so may result in loss of
benefits.
26. NAME OF ADOPTED CHILD (Last, First, Middle Initial)
a. DATE OF BIRTH
b. SEX (Check one)
(YYYYMMDD)
MALE
FEMALE
27. ADOPTION ARRANGED BY (Documentation attached) (Check one)
a. A state or local government agency.
b. A nonprofit adoption agency that is authorized by state or local law to place children for adoption.
c. Other source authorized by state or local law to place children for adoption.
DD FORM 2675, SEP 2006
PREVIOUS EDITION IS OBSOLETE.
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