2 SSN DD FORM 2894 MAR 2005 b. DATE SIGNED REPLACES DFAS-CL FORM 5890/2 WHICH IS OBSOLETE. Reset Adobe Professional 7. When you complete the form you must enter your Social Security Number and sign the form. Forms or letters that contain incorrect SHARE percentages will be returned for correction. Forms or letters that do not contain your Social Security Number or your signature will be returned to you unprocessed. DD FORM 2894 BACK MAR 2005. DESIGNATION OF BENEFICIARY INFORMATION Read Privacy Act Statement and Instructions on back before completing this form* After completing this form make a copy for your records. 1. a* RETIRED MEMBER S NAME Last first middle initial 2. DESIGNATED BENEFICIARY INFORMATION 2 FULL NAME Last first middle initial a* b. SSN 3 SSN 4 RELATIONSHIP 1 SHARE 5 ADDRESS Street Apartment Number City State and ZIP Code b. c* d. e. 3. IF YOU DO NOT ELECT TO DESIGNATE BENEFICIARIES ABOVE PLEASE PROVIDE THE INFORMATION REQUESTED BELOW FOR FAMILY MEMBERS WHO MAY BE CONTACTED IN THE EVENT OF YOUR DEATH. 0 PRIVACY ACT STATEMENT AUTHORITY Executive Order 9397 10 U*S*C. Sections 1477 and 2771 P. L* 92-425 September 21 1972 as amended* PRINCIPAL PURPOSE S The purpose in collecting this information is so that the retiree can designate a beneficiary to receive any retired pay still owed to that member upon his or her death. ROUTINE USE S The information on this form may be disclosed as generally permitted under 5 U*S*C. Section 552 a b of the Privacy Act of 1974 as amended* It may also be disclosed outside of the Department of Defense to the Internal Revenue Service for tax purposes the Department of Veterans Affairs DVA for discontinuing DVA compensation or individuals authorized to receive retired pay on behalf of the retiree. In addition other Federal State or local government agencies which have identified a need to know may obtain this information for the purpose s identified in the DoD Blanket Routine Uses as published in the Federal Register. DISCLOSURE Disclosure is voluntary however failure to furnish the requested information will result in delays in payment of arrears of retirement pay and will result in the inability to pay the designated beneficiary. INSTRUCTIONS This form is intended to apply to any amounts you are due as a retired member on the date of your death including retired pay and if you are eligible Combat-Related Special Compensation CRSC. References to unpaid retired pay in this form include CRSC if applicable. Entitlement to retired pay stops on the date of your death. CRSC payments terminate on the first day of the month in which you die. In order to determine who should receive any retired pay or CRSC you are owed when you die this form should be completed and returned to Defense Finance and Accounting Service U*S* Military Retirement Pay P. O. Box 7130 London KY 40742-7130 By law you may designate a beneficiary or beneficiaries you wish to receive your unpaid retired pay. If you specifically elect to designate a beneficiary or beneficiaries you must list the names of the beneficiaries you desire in the top part of the form Item 2 their relationship to you Item 4 their SSN if available Item 3 and their address Item 5.
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