Dd Form 2790 - Custodianship Certificate To Support Claim On Behalf Of Minor Children Of Deceased Members Of The Armed Forces
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2OMB No. 0730-0010
CUSTODIANSHIP CERTIFICATE TO SUPPORT CLAIM ON BEHALF OF
OMB approval expires
MINOR CHILDREN OF DECEASED MEMBERS OF THE ARMED FORCES
Feb 29, 2020
The public reporting burden for this collection of information is estimated to average 10 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, Washington Headquarters Services, Executive Services Directorate, Directives DIvision, 4800 Mark Center Drive, East
Tower, Suite 03F09, Alexandria, VA 22350-3100 (0730-0010). 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 SEND YOUR COMPLETED 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., Chapter 73, Annuities Based on Retired or Retainer Pay; and E.O. 9397 (as amended), Numbering System for Federal
Accounts Relating to Individual Persons.
PRINCIPAL PURPOSE(S): This information is required to identify the custodian of an unmarried minor child(ren), incapacitated child, or child at least
18 but under 22 who is attending school and is a child of a deceased military member. The Defense Finance and Accounting Service (DFAS) requires
this information to pay or release Survivor Benefit Plan (SBP), and Reserve Component Survivor Benefit Plan (RCSBP) funds and/or arrears of retired
pay for the benefit of the children. Applicable SORN: T7347b, Defense Military Retiree and Annuity Pay System Records at:
( ).
PIA for Defense Retired and Annuitant System is available at:
( ).
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" at Uses.aspx.
DISCLOSURE: Voluntary; however, if DFAS does not receive this information it may result in non-payment of annuity.
1. MEMBER'S NAME (Last, First, Middle)
2. SSN
3. CHILD(REN) IN CUSTODY
FULL NAME (Last, First, Middle)
SSN
DATE OF BIRTH
RELATIONSHIP TO MEMBER
a.
b.
c.
d.
4. CUSTODIAN'S RELATIONSHIP TO ABOVE CHILD(REN)
5. CERTIFICATION (X as applicable)
This is to certify that the above named child(ren) is an (are) unmarried minor child(ren) of a deceased military member.
This is to certify that the above named child(ren) is (are) at least 18 but under 22 attending a school, technical or vocational institute, junior
college, university or comparable recognized educational institution.
This is to certify that the above named child(ren) is (are) in my care and is incapable of self-support because of a mental or physical
incapacity incurred before his/her 18th birthday or incurred before age 22 during a full-time course of study or training.
A physician's statement attesting the date and extent of incapacity is attached.
I further certify that no legal fiduciary appointment is contemplated on behalf of the child(ren) listed above and that all funds received will be
used for their care and benefit. Also, I will immediately notify Defense Finance and Accounting Service, US Military Annuitant Pay, 8899 E. 56th
Street, Indianapolis, IN 46249-1300, if the status of (any of) the child(ren) is terminated for any reason whatsoever.
WARNING: The 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 (Act of June 25, 1948, 18 U.S.C. 287, 1001).
a. PRINTED NAME OF CUSTODIAN
b. SIGNATURE OF CUSTODIAN
c. DATE SIGNED
(Last, First, Middle Initial)
d. ADDRESS
STREET
CITY
STATE
ZIP CODE
6. REMARKS
DD FORM 2790, MAR 2017
PREVIOUS EDITION IS OBSOLETE.
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