Dd Form 2675, Reimbursement Request For Adoption Page 2
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328. EXPENSES INCURRED (Complete as applicable and attach documentation)
$
a. Public and private agency fees.
b. Temporary foster care charges when such care is required before the placement of the child.
c. Legal fees, including court costs.
d. Medical expenses, including hospital expenses for the newborn infant, for medical care furnished
the adoptive child before the adoption, and for physical examinations of the biological mother of
the child to be adopted.
e. Placement fees, including fees charged adoptive parents for counseling.
f. Expenses relating to pregnancy and childbirth for the biological mother, including counseling and
maternity costs.
0.00
g. Subtotal of expenses listed above (Items 28.a. through 28.f.).
h. Amount of reimbursement previously applied for and/or received under any other adoption benefits
program administered by the Federal government or under such program administered by a State or
Local government.
0.00
i. Total expenses (Subtotal (Item 28.g.) minus any reimbursements in Item 28.h.).
SECTION V - ARMED FORCES MEMBER CERTIFICATION
I certify that the above information and expenses are true and correct to the best of my knowledge. I understand
and agree that reimbursement of expenses is limited to $2,000 per adopted child with maximum reimbursement of
$5,000 in any calendar year to a member, or couple where both spouses are members of the Armed Forces
(including the U.S. Coast Guard). I agree not to seek further reimbursement under this program for the adoption
of this child.
I further certify that neither I nor my spouse have received a reimbursement under any other adoption benefit
program administered by the Department of Defense. To the best of my knowledge, I am the only active duty
.
member of the Armed Forces or U.S. Coast Guard claiming reimbursement of
$
29. MEMBER'S NAME (Last, First, Middle Initial)
a. MEMBER'S SIGNATURE
b. DATE SIGNED (YYYYMMDD)
(Print or Type)
SECTION VI - AUTHORIZATION AND CERTIFICATION FOR ADOPTION EXPENSES
I certify that, based upon information provided and documentation attached, the below named individual is eligible
for reimbursement of adoption expenses, subject to final approval by the Defense Finance and Accounting Service
(DFAS).
30. NAME OF ACTIVE DUTY MEMBER (Last, First, Middle Initial)
31. SSN
32. TITLE OF CERTIFYING OFFICIAL (Commanding Officer or Designee) (Print or Type)
a. TYPED NAME (Last, First, Middle Initial)
b. DSN
c. COMMERCIAL TELEPHONE
d. SIGNATURE
e. DATE SIGNED (YYYYMMDD)
33. DUTY STATION DELIVERY ADDRESS (APO/FPO Designation and ZIP Code)
DD FORM 2675, SEP 2006
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