Fillable Dd Form 2761 - Personal Check Cashing Agreement printable pdf download

OMB No. 0730-0005

OMB approval expires

PERSONAL CHECK CASHING AGREEMENT

Mar 31, 2010

The public reporting burden for this collection of information is estimated to average 30 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 (0730-0005). 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 THE ADDRESS OF THE AGENCY

WHICH PROVIDED THIS FORM.

PRIVACY ACT STATEMENT

AUTHORITY: 31 U.S.C. Section 3342, E.O. 9397, and DoD Financial Management Regulation (DoDFMR) 7000.14-R, Volume 5, Chapter 4.

PRINCIPAL PURPOSES: This form is designed exclusively to help overseas and afloat DoD disbursing activities, expedite the collection

process of dishonored checks overseas and afloat.

ROUTINE USES: The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act of

1974, as amended. It may also be disclosed outside of the Department of Defense to Federal, state, or local government agencies, which have

identified a need to know, for the purpose(s) identified in the DoD Blanket Routine Uses as published in the Federal Register.

DISCLOSURE: Voluntary; however, failure to provide the requested information may result in refusal to cash personal checks.

PLEASE PRINT OR TYPE ALL INFORMATION.

1. NAME (Last, First, Middle)

2. SOCIAL SECURITY NUMBER

3. ORGANIZATION/LOCATION

4. RANK/GRADE

5. DUTY TELEPHONE NUMBER

(Include Area Code)

6. BRANCH OF SERVICE

7. SUPERVISOR'S NAME (Last, First, Middle Initial)

8. SUPERVISOR'S TELEPHONE NUMBER

(Include Area Code)

9. HOME ADDRESS (Street, Apartment Number, City, State, ZIP Code)

10. HOME TELEPHONE NUMBER

11. DRIVER'S LICENSE NUMBER

12. DRIVER'S LICENSE STATE

(Include Area Code)

POWER OF ATTORNEY

I desire to execute a power of attorney and I appoint and by these presents do make, constitute and appoint the below listed

individual(s) my true and lawful attorney(s)-in-fact to draw, make, endorse, and cash personal checks drawn upon any account

which I may have as sole or joint owner. Any act performed hereunder for me or from my account shall be binding on me, my

heirs, legal and personal representatives and assigns. Transactions under this authority shall be in my name and all

endorsements and instruments executed by my attorney shall contain my name, followed by that of my attorney and the

designation "Attorney-in-Fact".

13. AUTHORIZED AGENT

14. AUTHORIZED AGENT

15. AUTHORIZED AGENT

16. AUTHORIZED AGENT

"In consideration of the extension of the privilege to have personal checks cashed by a Department of Defense finance/

disbursing officer, I hereby freely and voluntarily consent to the immediate collection from my current pay, without prior notice or

prior opportunity to be heard, the face value of any check cashed by myself or my authorized agents, plus any charges

assessed against the government by a financial institution, in the event such instrument is dishonored and returned for

insufficient funds or closed accounts."

17. REQUESTOR'S SIGNATURE

18. DATE

DD FORM 2761, APR 2007

PREVIOUS EDITION IS OBSOLETE.

LOCAL REPRODUCTION AUTHORIZED.

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Dd Form 2761 - Personal Check Cashing Agreement

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