Form Navpers 1800/13 - Questionnaire For Applicants For Retired Pay
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1FILLABLE FORM
SUPPORTING DIRECTIVE BUPERSINST 1001.39
QUESTIONNAIRE FOR APPLICANTS FOR RETIRED PAY
PRIVACY ACT
AUTHORITY: 10 U.S.C. 12531, 12739
PURPOSE: The purpose of this data is to determine the amount of retired pay to which a retired navy member may be entitled and will be used to
substantiate such claims for retired pay.
ROUTINE USES: To designated DOD personnel who capture or compute retired pay request action.
DISCLOSURE: Completion of this form is mandatory. Failure to provide the required data may result in the inability to process the application.
COMPLETE AND SIGN THIS IN DUPLICATE AND SUBMIT WITH DD FORM 108 TO
COMMANDER, NAVY PERSONNEL COMMAND (PERS-9), MILLINGTON, TN 38055-0049
VIA THE APPROPRIATE CHAIN OF COMMAND.
CHECK YES/NO OR FURNISH YOUR ANSWER AS APPROPRIATE
YES
NO
1. DO YOU NOW RECEIVE AN AWARD FROM THE VETERANS ADMINISTRATION?
2. HAVE YOU RECEIVED AN AWARD FROM THE VETERANS ADMINISTRATION SINCE YOUR 60TH BIRTHDAY?
(ANSWER ONLY IF YOU ARE OVER AGE 60)
3. DO YOU HAVE A CLAIM PENDING WITH THE VETERANS ADMINISTRATION?
4. IF YOUR ANSWER TO ANY QUESTIONS ABOVE IS "YES", PLEASE FURNISH THE FOLLOWING INFORMATION.
ADDRESS OF PAYING OFFICE:
CLAIM NUMBER:
EFFECTIVE DATE(S) OF AWARD:
MONTHLY AMOUNT(S):
5. ARE YOU CURRENTLY EMPLOYED IN ANY CAPACITY WITH THE U.S. GOVERNMENT?
6. IF SO, WERE YOU EMPLOYED ON OCTOBER 13, 1978 AND EMPLOYED CONTINOUSLY WITHOUT HAVING A 3 DAY BREAK
IN SERVICE?
7. IF YOUR ANSWER IS "YES", FURNISH THE FOLLOWING INFORMATION:
EFFECTIVE DATE
:
(S)
GROSS ANNUAL BASIC RATE
OF PAY:
(S)
8. HAVE YOU BEEN PREVIOUSLY RELEASED OR DISCHARGED FROM THE SERVICE FOR NON-DISABILITY REASON AND
RECEIVED A
SEVERANCE PAY?
"LUMP SUM"
9. IF YOUR ANSWER TO 8 IS "YES" FURNISH THE FOLLOWING INFORMATION:
A COPY OF DISCHARGE ORDERS:
DATE OF DISCHARGE:
AMOUNT OF SERVERANCE PAY::
10. DO YOU NOW RECEIVE A PENSION, COMPENSATION, ETC., FROM ANY OTHER BRANCH OF THE U.S. GOVERNMENT?
11. ANSWER ONLY IF YOU ARE NOW OVER 60: HAVE YOU RECEIVED A PENSIONN, COMPENSATION, ETC., FROM ANY
OTHER BRANCH OF THE U.S. GOVERNMENT SINCE YOUR 60TH BIRTHDAY?
12. IF YOUR ANSWER TO 10 OR 11 ABOVE IS "YES", PLEASE FURNISH THE FOLLOWING INFORMATION:
NAME AND ADDRESS OF PAYING AGENCY:
EFFECTIVE DATE
:
(S)
MONTHLY AMOUNT
:
(S)
14. MEMBER'S SIGNATURE:
13. MEMBER'S NAME
:
15. GRADE:
16. SSN AND DESIG:
17. DATE:
(LAST, FIRST, MIi)
NAVPERS 1800/13 (04-07)
FOR OFFICIAL USE ONLY
S/N: 0106-LF-981-3100
PRIVACY SENSITIVE
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