Dd Form 2851 - Request To Correct Thrift Savings Plan (Tsp) Agency Error
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1
2REQUEST TO CORRECT THRIFT SAVINGS PLAN (TSP) AGENCY ERROR
(Read Privacy Act Statement, Penalty Statement, and Instructions on back before completing form.)
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C 8432a, Payment of lost earnings; and 5 CFR 1606, Lost Earnings Attributable to Employing Agency Errors.
PRINCIPAL PURPOSE(S): The information on this form will be used to correct errors in member's TSP withholdings and for computer matching programs with
Federal, state, and local agencies as authorized by law. It will also be used for maintaining a record of member's claim for lost earnings.
ROUTINE USE(S): To the Treasury Department to provide information on check issues and electronic funds transfers. To Federal, state, and local authorities
for authorized computer matching programs, and Social Security Administration to report earned wages. The remaining routine uses are available in the
applicable system of records notices T7340, Defense Joint Military Pay System-Active Component; and T7344, Defense Joint Military Pay System-Reserve
Component, located at:
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in the member not being able to claim TSP lost earnings.
PENALTY STATEMENT
Any person knowingly making false, fictitious, or fraudulent claims upon or against the United States Government may be imprisoned for up to
five years (18 USC 287 and 1001, and 31 USC 3729).
4. DoD ID NUMBER
1.
NAME
2.
GRADE
3. DATE OF BIRTH
(Last, First, Middle Initial)
(YYYYMMDD)
6.
MEMBER'S UNIT
NAME AND ADDRESS
5.
DUTY
TELEPHONE NUMBER
(Include area code)
a. DSN
b.
COMMERCIAL
8.
INPUT SOURCE
(Unit, Address, and Telephone Number)
7.
BRANCH
OF SERVICE
(X one)
AIR FORCE
COAST GUARD
ARMY
PUBLIC HEALTH
NAVY
NOAA
MARINE CORPS
10. PAYROLL DATE
11. DATE PAYMENT MADE TO NFC
(YYYYMMDD)
9.
STATUS
(X one)
(YYYYMMDD)
ACTIVE DUTY
GUARD
12. CLAIMANT'S BRIEF EXPLANATION OF ERROR
13. INPUT SOURCE'S EXPLANATION OF EXTENUATING CIRCUMSTANCES
14. DOCUMENTATION ATTACHED TO SUPPORT CLAIM
(X as appropriate)
LEAVE AND EARNINGS STATEMENTS
TSP PARTICIPANTS STATEMENTS
TSP FORM 1, TSP ELECTION FORM
15. FOR OFFICIAL USE ONLY
16. CLAIMANT
17. INPUT SOURCE/COMMANDER
a. SIGNATURE
b.
DATE
SIGNED
a. SIGNATURE
b.
DATE
SIGNED
(YYYYMMDD)
(YYYYMMDD)
c. E-MAIL ADDRESS
c. E-MAIL ADDRESS
DD FORM 2851, DEC 2017
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