Dd Form 2769 - Annuity Certain Military Surviving Spouses Application Form Page 2
Download a blank fillable Dd Form 2769 - Annuity Certain Military Surviving Spouses Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dd Form 2769 - Annuity Certain Military Surviving Spouses Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2SECTION V - LEGAL REPRESENTATIVE INFORMATION
(Court Appointed Guardian, Representative Payee, or Power of Attorney)
19. HAS A LEGAL REPRESENTATIVE BEEN APPOINTED FOR THE
20. IF A LEGAL REPRESENTATIVE HAS NOT BEEN APPOINTED WILL
PURPOSE OF RECEIVING THIS ANNUITY ON YOUR BEHALF?
ONE BE APPOINTED?
YES
NO
YES
NO
21a. NAME OF LEGAL REPRESENTATIVE (Last, First, Middle Initial)
b. ADDRESS OF LEGAL REPRESENTATIVE (Street (or P.O. Box),
Suite Number, City, State, ZIP Code)
c. TELEPHONE NUMBER (Include Area Code)
SECTION VI - CERTIFICATION AND SIGNATURE
(Must be signed)
22a. APPLICANT/LEGAL REPRESENTATIVE'S SIGNATURE
b. DATE (YYYYMMDD)
23a. FIRST WITNESS OR NOTARY SIGNATURE
b. DATE (YYYYMMDD)
c. ADDRESS OF FIRST WITNESS (Include ZIP Code)
24a. SECOND WITNESS SIGNATURE
b. DATE (YYYYMMDD)
c. ADDRESS OF SECOND WITNESS (Include ZIP Code)
TRUTHFULNESS STATEMENT
All statements made in this application must be true to the best of your knowledge. No evidence necessary for settlement of the
claim or establishment of the annuity should be suppressed or withheld.
(U.S. Code, Title 18, Sec. 287, 1001, provides that an individual
shall be fined under this title or imprisoned not more than 5 years, or both.)
WHERE TO REQUEST INFORMATION AND SEND YOUR APPLICATION
The following documents are needed to determine your eligibility. Please include them with your application.
(1) A copy of a retirement order or copy of Notice of Retirement Eligibility or other official service document showing deceased
member's retired status;
(2) A copy of the deceased retiree's final DD Form 214 (Certificate of Discharge);
(3) A certified true copy of the deceased retired member's death certificate; and
(4) A certified true copy of your certificate of marriage to the deceased retired member.
Upon completion of this form, send it to the office listed below for the Service of the deceased member.
U.S. ARMY - Army Retirement Services Office, Taylor Bldg., RM 6058C, 2530 Crystal Drive, Arlington, VA 22202-3941
U.S. NAVY - Office of the Chief of Naval Operations (OPNAV N135C), 5720 Integrity Dr., Millington, TN 38055-6220
U.S. AIR FORCE - HQ AFPC/DPSIAR, 550 C Street West, Suite 8, Randolph AFB, TX 78150-4713.
U.S. MARINE CORPS - Retired Services Section, Separation and Retirement Branch, 3280 Russell Road, Quantico, VA
22134-5103.
U.S. COAST GUARD and NOAA - Commanding Officer (RAS), USCG Pay and Personnel Center, 444 S.E. Quincy Street, Topeka,
KS 66683-3591.
U.S. PUBLIC HEALTH SERVICE - Compensation Branch, 5600 Fishers Lane, Room 4-50, Rockville, MD 20857.
If you have questions or need help completing this application, please contact the office of the appropriate Service above or for
deceased Army personnel contact the Retirement Services Office at your nearest Army installation.
SERVICE CERTIFICATION - FOR OFFICE USE ONLY
I certify that the above applicant is qualified for benefits under the Annuity for Certain Military Surviving Spouses and authorize
payment.
25a. PRINTED NAME OF AUTHORIZING OFFICIAL
b. TITLE
c. SERVICE
(Last, First, Middle Initial)
f. DATE (YYYYMMDD)
d. TELEPHONE NUMBER
e. SIGNATURE
(Include Area Code)
DD FORM 2769 (BACK), OCT 2012
Reset
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ptd - Claim For Real Property Tax Deduction On Dwelling House Of Qualified New Jersey Resident Senior Citizen, Disabled Person, Or Surviving Spouse/surviving Civil Union Partner
Financial
Form Dte 105i - Homestead Exemption Application For Disabled Veterans And Surviving Spouses
Financial
Form Sdat - 4b1 - Application For Exemption For Surviving Spouses Of Disabled Veterans Receiving Dic Benefits
Financial
Form Dte 105a - Homestead Exemption Application For Senior Citizens, Disabled Persons And Surviving Spouses
Financial
Form Sdat-4b1 - Application For Exemption For Surviving Spouses Of Disabled Veterans Receiving Dic Benefits
Financial
Form Dte 105a - Homestead Exemption Application For Senior Citizens, Disabled Persons And Surviving Spouses
Financial
Form Dte 105b - Continuing Homestead Exemption Application For Senior Citizens, Disabled Persons And Surviving Spouses
Financial
Related Categories
Parent category: Business