Dd Form 2947-3 - Tricare Young Adult Application Page 4
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4SPONSOR'S SSN/DBN:
SECTION V - PAYMENT OF TRICARE YOUNG ADULT PREMIUMS
21. PREMIUM PAYMENT METHOD
(X and complete as applicable.) (See for current rates.)
Failure to complete both parts a. and b. of this section when requesting new and/or recurring TYA coverage will result in your
application being returned without action.
a. INITIAL PREMIUMS
(Two months of initial premiums are required.)
Check/Money Order/Cashier's Check
PAYMENT AMOUNT: $
(Enclose applicable premium payable to contractor on first page.)
Visa/MasterCard Credit or Debit Card:
CARD NUMBER:
EXPIRATION DATE (MM/YYYY):
NAME OF
CARDHOLDER
CARDHOLDER:
SIGNATURE:
CARDHOLDER
BILLING ADDRESS:
b. RECURRING AUTOMATED MONTHLY PREMIUMS
(Recurring monthly premiums must be paid via a Recurring Credit Charge on a
Visa/MasterCard credit or debit card or an Electronic Funds Transfer from a checking or savings account; either option is initiated and
maintained by your servicing contractor. Failure to ensure premiums can be paid monthly via automated means will result in termination of TYA
coverage.)
Use same Visa/MasterCard Credit or Debit Card information used for initial payment of premiums.
Other Visa/MasterCard Credit or Debit Card:
CARD NUMBER:
EXPIRATION DATE (MM/YYYY):
NAME OF
CARDHOLDER
CARDHOLDER:
SIGNATURE:
CARDHOLDER
BILLING ADDRESS:
Electronic Funds Transfer (EFT).
From:
Checking (Optional - attach voided check)
or
Savings
NAME AND ADDRESS OF
FINANCIAL INSTITUTION
TELEPHONE NUMBER OF
NAME ON ACCOUNT
FINANCIAL INSTITUTION
BANK OR ABA ROUTING NUMBER
ACCOUNT NUMBER
ACCOUNT HOLDER
SIGNATURE
DD FORM 2947-3, SEP 2016
Page 4 of 4 Pages
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