Dd Form 2769 - Annuity Certain Military Surviving Spouses Application Form

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APPLICATION FOR ANNUITY
CERTAIN MILITARY SURVIVING SPOUSES
(Please type or print information in ink)
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Section 1448 note; DoD Financial Management Regulation, Volume 7B, Chapter 61; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To be used by a qualified surviving spouse to apply for an annuity for certain military surviving spouses.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in denial of benefits.
SECTION I - INFORMATION CONCERNING DECEASED MEMBER
1. NAME OF DECEASED RETIREE (Last, First, Middle)
2. SOCIAL SECURITY NUMBER OR
3. DATE OF BIRTH (YYYYMMDD)
SERVICE NUMBER
SECTION II - ELIGIBILITY
Please answer the following questions to help determine your eligibility. Place an X to indicate the appropriate answer. Enter dates as
YYYYMMDD. If you still wish to apply after completing this section, please complete Sections III through VI.
4. DID THE DECEASED MEMBER DIE BEFORE MARCH 21, 1974, OR IN THE CASE OF A RESERVE MEMBER, DIE BEFORE OCTOBER 1,
YES Enter date of death:
NO
If you marked "NO", YOU ARE NOT ELIGIBLE.
5. WAS THE MEMBER RETIRED, OR IN THE CASE OF A RESERVE MEMBER ELIGIBLE FOR RETIREMENT BY COMPLETING OVER 20
YEARS OF QUALIFYING SERVICE?
YES Enter date retired, or in the case of a reserve member, date of retirement eligibility:
NO
If you marked "NO", YOU ARE NOT ELIGIBLE.
6. WERE YOU LEGALLY MARRIED TO THE DECEASED AT THE TIME OF DEATH?
YES Enter date of marriage:
NO
If you marked "NO", YOU ARE NOT ELIGIBLE.
7. HAVE YOU EVER REMARRIED?
YES Enter date of remarriage (See NOTE):
NO
NOTE: If you answered "YES" to Item 7, your eligibility for accruing additional benefits ended on the date you remarried. However, you
are eligible for benefits from the date your spouse died through the day before you remarried. Failure to apply within six years of the date
of remarriage will result in forfeiture of one day of benefits for each day of delay in submitting a claim.
b. TYPE OF BENEFIT:
8a. ARE YOU RECEIVING ANY OTHER MILITARY SURVIVOR ANNUITY OF ANY
If you are receiving SBP or MIW, YOU ARE
KIND ON THE RECORD OF THIS OR ANY OTHER DECEASED RETIREE?
SBP
NOT ELIGIBLE. If you are receiving DIC, any
YES Enter monthly amount:
MIW
payment under this annuity will be reduced by
the DIC amount.
NO
DIC
SECTION III - INFORMATION CONCERNING SURVIVING SPOUSE
10. SOCIAL SECURITY
11. DATE OF BIRTH
9. NAME (Last, First, Middle Initial)
12. CITIZEN OF WHAT COUNTRY?
NUMBER
(YYYYMMDD)
13. ADDRESS (Street, Apartment Number, City, State, ZIP Code)
14. TELEPHONE NUMBER
(Include Area Code)
SECTION IV - ELECTRONIC FUNDS TRANSFER (EFT)
Complete the following section to authorize Electronic Funds Transfer (EFT) if you are found qualified for benefits. Instead of completing this
section you may attach a voided personal check to authorize EFT.
15. ROUTING TRANSIT NUMBER (RTN) (9 digits)
16. ACCOUNT NUMBER
CHECKING
SAVINGS
17. NAME(S) OF ACCOUNT HOLDER(S)
18. FINANCIAL INSTITUTION
b. TELEPHONE NUMBER
a. NAME
(Include Area Code)
c. ADDRESS (Street, Suite Number, City, State, ZIP Code)
DD FORM 2769, OCT 2012
PREVIOUS EDITION IS OBSOLETE.
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