Fillable Dd Form 2789 Waiver/remission Of Indebtedness Application printable pdf download

OMB No. 0730-0009

WAIVER/REMISSION OF INDEBTEDNESS APPLICATION

OMB approval expires

(If more space is needed, continue on separate sheet(s). Identify each item by number.)

Nov 30, 2008

The public reporting burden for this collection of information is estimated to average 2 hours 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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon,

Washington, DC 20301-1155 (0730-0009). 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.

SEPARATED MILITARY OR FORMER CIVILIAN EMPLOYEES, RETURN COMPLETED FORM TO: DFAS-IN, DEPT. 3300 (WAIVER/REMISSION),

8899 EAST 56TH STREET, INDIANAPOLIS, IN 46249-3300.

ACTIVE DUTY MILITARY, GUARD/RESERVE, RETIRED OR ANNUITANT PAY RECIPIENTS, CIVILIAN EMPLOYEES, RETURN COMPLETED

FORM TO THE ADDRESS LISTED ON THE DEBT NOTIFICATION LETTER FOR COMPLETION OF BACK SIDE.

PRIVACY ACT STATEMENT

AUTHORITY: E.O. 9397 (SSN).

PRINCIPAL PURPOSE: To be used by civilian employees (current, former, or retired) and military members (active, separated, or retired), and

annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances, and expense reimbursement or

allowances for travel, transportation, and relocation; or in the case of enlisted members, remission of these debts.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the PA, this information may be disclosed to

the Department of Justice or to commercial credit agencies, whenever a financial status report is requested by the Department of Defense (DoD) for

use in administering the Federal Claims Collection Act. It may also be disclosed for any of the blanket routine uses as published in the Federal

DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data, including your Social Security Number, may prevent

consideration of the claim.

1. TYPE OF CLAIM (X one)

WAIVER

REMISSION

Authority for granting waiver: Active/Retired Military - 10 U.S.C. 2774; National Guard - 32 U.S.C. 716; Civilian - 5 U.S.C. 5584;

Annuitant - 10 U.S.C. 1442/1453. Remission: Army - 10 U.S.C. 4837; Navy - 10 U.S.C. 6161; Air Force - 10 U.S.C. 9837.

Note: Remission generally is applicable for active duty enlisted personnel only, see DoDFMR, Volume 7A.

SECTION I - CIVILIAN/MILITARY/RETIREE/ANNUITANT INFORMATION

2. NAME (Last, First, Middle Initial)

3. RANK/GRADE

4. SOCIAL SECURITY NUMBER

5. AGENCY/SERVICE

6. STATUS (X applicable block and provide date (YYYYMMDD) for end of enlistment period (EOE),

retirement (DOR), separation (DOS), or service computation date (SCD), as appropriate.)

ARMY

OTHER (Specify)

NAVY

ACTIVE

EOE:

SEPARATED

DOS:

AIR FORCE

GUARD/RESERVE

EOE:

DOD CIVILIAN

SCD:

MARINE CORPS

RETIRED

DOR:

ANNUITANT

7. CURRENT COMPLETE MAILING ADDRESS (Street, City, State,

8. PLACE OF ASSIGNMENT OR

9. TELEPHONE

(Include DSN or area code)

ZIP Code)

EMPLOYMENT

a. WORK

b. HOME

c. E-MAIL ADDRESS:

10. TYPE OF DEBT OR PAY AND ALLOWANCE ERRONEOUSLY PAID

11. GROSS DEBT AMOUNT

12. STATE THE DATE AND HOW YOU FIRST BECAME AWARE OF DEBT OR ERRONEOUS PAYMENT. (Attach notification, if available.)

13. IF YOU WERE AWARE OF DEBT OR ERRONEOUS PAYMENT, EXPLAIN THE ACTIONS YOU TOOK TO CORRECT SITUATION.

14. REASON FOR REQUESTING WAIVER/REMISSION AND WHY YOU FEEL IT SHOULD BE APPROVED (Financial hardship applies ONLY to

REMISSION and if claimed, a financial statement must be attached.)

15. FOR ANNUITANTS, PROVIDE NAME, SSN AND DATE DECEASED OF MILITARY MEMBER/SPONSOR.

16. ATTACH COPIES OF ALL PERTINENT DOCUMENTS (Such as Request for BAH, Statement of Service, Separation Worksheet,

DD Form 214, Travel Voucher, Notification of Personnel Action). (If not available, please explain.)

17.a. IF MILITARY OR CIVILIAN, DID YOU RECEIVE LEAVE AND EARNINGS STATEMENT(S)?

YES

b. IF MILITARY OR CIVILIAN, DID YOU REQUEST THEM ON EMSS/MYPAY?

YES

c. IF RETIREE OR ANNUITANT, DID YOU RECEIVE AN ACCOUNT STATEMENT?

YES

d. IF RETIREE OR ANNUITANT, DID YOU REVIEW THEM?

YES

(If answer to a. or c. is Yes, attach a copy of statement covering before, during, and after period. If No, explain why.)

18. HAVE YOU FILED FOR A CORRECTION OF MILITARY RECORDS?

YES

19. I certify the above statements are true and correct to the best of my knowledge. The information presented may be referred to the

appropriate investigating office for verification. I understand the penalty for a false claim is a maximum fine of $10,000 or a maximum

imprisonment of 5 years, or both.

a. SIGNATURE

b. JOB TITLE/CAREER FIELD

c. DATE SIGNED

DD FORM 2789, MAY 2008

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Dd Form 2789 Waiver/remission Of Indebtedness Application

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