CERTIFICATE OF ELIGIBILITY FOR RETIRED MEMBERS
(Please read Privacy Act Statement on back before completing this form.)
Complete this form and return it in the enclosed envelope. Address any comments or questions to Defense Finance and
Accounting Service, US Military Retired Pay, 8899 E. 56th Street Indianapolis, IN 46249-1200. Reply must be received
within 30 days to ensure continued receipt of your retired pay. This form must be notarized.
1. RETIRED MEMBER'S NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY
3. DATE OF BIRTH
4. RETIREMENT DATE
I CERTIFY THAT I AM ELIGIBLE TO CONTINUE RECEIVING RETIRED PAY.
5.a. RETIRED MEMBER'S SIGNATURE
b. DATE (YYYYMMDD)
SEAL OF NOTARY PUBLIC
6.a. NOTARY PUBLIC'S SIGNATURE
b. DATE (YYYYMMDD)
DD FORM 2892, APR 2017
PREVIOUS EDITION IS OBSOLETE.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C., Chapters 53, 61, 63, 65, 67, 69, 71, 73, 74; 10 U.S.C. Sec. 1059, and
1408(h); 38 U.S.C. Sec. 1311 and 1313; Pub. L. 92-425; Pub. L. 102-484 Sec. 653; Pub. L. 103-160 Sec. 554 and 1058; Pub. L. 105-261,
Sec. 570; DoDI 1342.24, Transitional Compensation for Abused Dependents; DoD Financial Management Regulation 7000.14-R, Volume
7B and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): This form is used to verify eligibility of the member to receive military retired pay. Applicable SORNs: T7347b.
ROUTINE USE(S): Certain "Blanket Routine Uses" for all DoD maintained systems of records have been established that are applicable to
every record system maintained within the Department of Defense, unless specifically stated otherwise within the particular record system
notice. These additional routine uses of the records are published only once in each DoD Component's Preamble in the interest of
simplicity, economy and to avoid redundancy.
DISCLOSURE: Voluntary; however, failure to complete this card may result in non-receipt of payments. The Social Security Number is
required to correctly identify the retiree account information.
DD FORM 2892 (BACK), APR 2017
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