RETIREE CHANGE OF ADDRESS REQUEST/STATE TAX WITHHOLDING AUTHORIZATION
(Read Privacy Act Statement before completing this form.)
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9397; P.L. 92-425, effective September 21, 1972, as amended; and 10 U.S.C. 1401.
PRINCIPAL PURPOSE(S): To change a member's address in the military retired pay system, and allow the member to
start, stop, or change tax withholding information.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552(a)(b)
of the Privacy Act. It may also be disclosed outside of the Department of Defense to the Internal Revenue Service
relating to an individual's claim for tax withholding, to the Department of Veterans Affairs (DVA) for establishment,
changes, or discontinuing of DVA compensation to a retiree. In addition, other Federal, state, or local government
agencies, which have identified a need to know, may obtain this information for the purpose(s) identified in the DoD
Blanket Routine Uses as published in the Federal Register.
DISCLOSURE: Voluntary; however, failure to furnish the requested information could result in non-receipt of payments/
correspondence and/or incorrect deductions from your retired pay.
PART I - CHANGE OF ADDRESS
(Please print all information.)
1. MEMBER'S NAME (Last, First, Middle Initial)
2. SSN
3. NEW CORRESPONDENCE ADDRESS
a. OTHER ADDRESS INFORMATION (If applicable)
b. NUMBER AND STREET OR ROUTE
c. CITY AND STATE
d. ZIP CODE
4. NEW CHECK ADDRESS (Not to be used for a Financial Institution in the United States. If same as New Correspondence Address,
enter "SAME" in block 4.a.)
a. BANK (If foreign), TRUSTEE ADDRESS INFORMATION, OR OTHER (If applicable)
b. NUMBER AND STREET OR ROUTE
c. CITY AND STATE
d. ZIP CODE
PART II - STATE INCOME TAX WITHHOLDING AUTHORIZATION
(Please print all information.)
Deduction from military pay for state tax withholding is voluntary. Complete this form with or without a change of address
if you wish to start, change, or terminate state tax withholding.
5. MARK (X) ONLY ONE BOX BELOW. THIS FORM MUST BE SIGNED AND DATED.
a. I wish to start state income tax withholding from my payments for the state and monthly amount indicated below.
The monthly amount must be in whole dollars and not less than $10.00.
b. I wish to change my state and/or monthly amount for state tax withholding purposes as indicated below.
c. I authorize that state income tax withholding deduction from my pay be terminated.
d. STATE
e. WITHHOLDING AMOUNT
$
f. SIGNATURE
g. DATE SIGNED (YYYYMMDD)
RETURN COMPLETED AND SIGNED FORM TO:
Defense Finance and Accounting Service
US Military Retirement Pay
P.O. Box 7130
London, KY 40742-7130
DD FORM 2866, NOV 2003
REPLACES DFAS CL FORM 5110/5.
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