OMB No. 0730-0015
REQUEST FOR INFORMATION REGARDING DECEASED DEBTOR
OMB approval expires
Nov 30, 2010
PLEASE DO NOT RETURN YOUR FORM TO THE ORGANIZATION IN THE PARAGRAPH BELOW.
RETURN COMPLETED FORM TO: DEFENSE FINANCE AND ACCOUNTING SERVICES, 8899 EAST 56TH STREET, DEPARTMENT 3300
(ATTN: CUSTOMER OPERATIONS), INDIANAPOLIS, IN 46249-3300
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DD 20301-1155
(0730-0015). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not
display a currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: 31 U.S.C. Section 3111; P.L. 102-484, Sec. 614; Department of Defense Financial Management Regulation (DoDFMR) 7000.14-R,
Vol. 5; E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To seek information from state probate courts or executors of the deceased members' estates concerning the
establishment of an estate and to pursue collection of the indebtedness from the estate, as appropriate.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. 552a(b) of the Privacy Act. The "Blanket
Routine Uses" published at the beginning of the DoD compilation of systems of records notices also apply.
DISCLOSURE: Voluntary; however, if the information is not provided, it may cause a delay in the settlement of the debt owed by the member's estate.
1. DECEASED DEBTOR
a. NAME (Last, First, Middle)
c. HOME OF RECORD
The deceased debtor named above was indebted to the United States at the time of death. Please complete items
below and return this form. Your assistance is appreciated.
2. DATE OF REQUEST
3a. SIGNATURE OF REQUESTOR
b. PRINTED NAME
4. WAS AN ESTATE ESTABLISHED?
YES (If Yes, complete Items 5 and 6 below)
5. NAME AND ADDRESS OF ATTORNEY, ADMINISTRATOR, OR EXECUTOR
6. ARE ANY OF THE INDIVIDUALS AT LEFT MEMBERS
OF THE IMMEDIATE FAMILY (Please specify)
7. ARE SPECIAL CLAIM FORMS AVAILABLE?
YES (If Yes, please provide)
9a. NAME OF INDIVIDUAL COMPLETING FORM
DD FORM 2840, JUN 2008
PREVIOUS EDITION IS OBSOLETE.
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