Fillable Dd Form 2828 - Physician Certificate For Child Annuitant printable pdf download

OMB No. 0730-0011

PHYSICIAN CERTIFICATE FOR CHILD ANNUITANT

OMB approval expires

Oct 31, 2009

The public reporting burden for this collection of information is estimated to average 2 hours 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 (0730-0011). 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.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO:

Defense Finance and Accounting Service, US Military Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C., Sections 1435 and 1447; and E.O. 9397.

PRINCIPAL PURPOSE(S): The Survivor Benefit Plan (SBP) and the Retired Serviceman's Family Protection Plan (RSFPP), provide for the coverage

of children who are unmarried and incapable of self-support because of mental and/or physical incapacitation. If the incapacitation is temporary,

recertification of this incapacitation is required every 2 years when the child annuitant is age 18 or over. This certification is necessary in order to

continue payment of the annuity.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records, or information

contained therein, may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: to the Internal Revenue

Service, the Department of Veterans Affairs, or trustees or guardians of survivors (children). It may also be disclosed for any of the "Blanket Routine

Uses" as published at the beginning of the DFAS compilation of systems of record notices.

DISCLOSURE: Voluntary; however, if DFAS does not receive this information, the annuity payments will stop.

NOTE: Penalty for presenting false claims or making false statements in connection with claims is a fine of not more than $10,000 or imprisonment for

not more than 5 years, or both (18 U.S.C. 1001).

1. DECEASED MEMBER'S

2. ANNUITANT'S NAME (Last, First, Middle Initial)

3. DATE OF BIRTH

4. ANNUITANT'S SSN

SSN

(YYYYMMDD)

5. BRIEF DESCRIPTION OF MEDICAL/PSYCHIATRIC DIAGNOSIS

6. DATE CONDITION BEGAN (YYYYMMDD)