Dd Form 2944 - Claim For Retroactive Stop Loss Payment Page 2

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CLAIM FOR RETROACTIVE STOP LOSS PAYMENT

THIS PROGRAM ENDS ON OCTOBER 21, 2010 AND THIS CLAIM MUST BE FILED BY OCTOBER 21, 2010. Please type or print legibly.

RETURN YOUR CLAIM TO THE SERVICE UNDER WHICH YOU SERVED WHILE ON ACTIVE DUTY:

DEPARTMENT OF THE AIR FORCE:

DEPARTMENT OF THE ARMY:

Active, retired and former Air Force members:

Reserve component members:

It is preferred that applicants submit on-line

E-mail:

applications to the U.S. Army Stop Loss Program

E-mail: afpc.dpsos.stoploss@randolph.af.mil

arpc.contactcenter@arpc.denver.af.mil

Office, via the web-based, on-line system at

Fax: (210) 565-4599 or DSN: 665-4599

Fax: (478) 327-2215 or DSN 497-2215

https:// Alternatively,

Mail: AFPC/DPSOS (Stop Loss Section)

Mail: HQ ARPC/DPS (Stop Loss Section)

hard copy signed and dated applications may be

550 C. Street West, Suite 3

6760 E. Irvington Place

mailed to:

Randolph AFB, TX 78150-4713

Denver, CO 80280

E-mail: retrostoplosspay@conus.army.mil

Mail: 5109 Leesburg Pike, Suite 302

Falls Church, VA 22041

Telephone: (877) 736-5554 toll free

U.S. MARINE CORPS:

It is preferred that applicants submit on-line applications to the Marine Corps Stop Loss Program

DEPARTMENT OF THE NAVY:

Office (SLPO), via the web-based, on-line Stop Loss Case Management System (SLCMS) at

the following URL: https:// Alternatively, hard copy signed and

Commander

dated applications may be mailed to:

Navy Personnel Command

Headquarters U.S. Marine Corps

PERS 832

Manpower and Reserve Affairs MID/SLPO

5720 Integrity Drive

3280 Russell Rd.

Millington, TN 38055-8320

Quantico VA 22134-5103

Telephone: (901) 874-4427, DSN: 882-4427

SLPO Organizational Mailbox: stoploss@usmc.mil

Email: NXAG_N132C@navy.mil

SLPO toll free phone number: 1-877-242-2830

1. MILITARY MEMBER

2. CLAIMANT (If other than Member)

b. SSN

(Last 4

a. NAME

(Last, First, Middle Initial)

digits)

3. SERVICE AT TIME OF ACTIVE DUTY

4. SERVICE STATUS AT START OF STOP LOSS

(X one)

ARMY

NAVY

ACTIVE DUTY

ANG

IRR

RESERVE

AIR FORCE

MARINE CORPS

OTHER SERVICE

(Specify)

5. APPLICANT CURRENT STATUS

6. APPLICANT SERVICE STATUS

(X one)

LIVING

DECEASED*

INCAPACITATED

RETIRED

SEPARATED

ACTIVE DUTY

* If deceased, attach documentation establishing the beneficiary.

7. CLAIMED STOP LOSS PERIOD**

**Dates on eligible Active Duty during covered stop loss time periods. If

a. FROM

b. TO

(YYYYMMDD)

more than one claim, list each claim separately on one attachment to this

application and submit.

8. CLAIMANT'S MAILING ADDRESS/CONTACT INFORMATION

a. STREET/APARTMENT NUMBER

b. CITY

c. STATE

d. 5-DIGIT ZIP CODE

e. COUNTRY CODE

f. TELEPHONE NUMBER

g. EMAIL ADDRESS

h. STATE OF LEGAL

RESIDENCE

(If overseas)

(Include area code)

9. PAYMENT DISBURSEMENT

(X one)

a. DIRECT DEPOSIT/ELECTRONIC FUNDS TRANSFER:

b. CHECK

(1) SAVINGS

(2) CHECKING

10. FINANCIAL INFORMATION

a. BANK NAME

b. ACCOUNT NUMBER

c. BANK ROUTING NUMBER

11. CLAIMANT AUTHORIZATION

I hereby authorize the Military Department under which I served while on Active Duty and other authorized Federal agencies to obtain any

information required including, but not limited to, Internal Revenue Service (IRS), DFAS, etc. This authorization is valid for one year from the date this

form was signed. I understand I have a right to challenge the accuracy and completeness of any information contained in the report pertaining to my

case. I also understand that this information will be treated as privileged and confidential information. Case files are handled under the procedures for

safeguarding records.

I hereby release any individual, including records custodians, any component of the U.S. Government supplying information, from all liability for

damages that may result on account of compliance, or any attempts to comply with this authorization. This release is binding, now and in the future,

on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the

original release signed by me.

a. CLAIMANT SIGNATURE (Hard copy signature is MANDATORY)

b. DATE SIGNED (YYYYMMDD)

DD FORM 2944, MAR 2010

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