Form DD Form 2840 DD Form 2840 Request For Information Regarding Deceased Debtor

REQUEST FOR INFORMATION REGARDING DECEASED DEBTOR

OMB No. 0730-0015
OMB approval expires
Aug 31, 2007

The public reporting burden for this collection of information is estimated to average 5 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 (0730-0015). 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 DFAS-PODC/DE, 6760 EAST IRVINGTON PLACE, DENVER, CO 80279-7000.
1. DECEASED DEBTOR
a. NAME (Last, First, Middle)

b. SSN

c. HOME OF RECORD

The deceased debtor named above was indebted to the United States at the time of death. Please complete
items below and return this form. Your assistance is appreciated.
2. DATE OF REQUEST

3a. SIGNATURE OF REQUESTOR

b. PRINTED NAME

c. TITLE

d. GRADE

4. WAS AN ESTATE ESTABLISHED?
YES (If Yes, complete Items 5 and 6 below)

NO

5. NAME AND ADDRESS OF ATTORNEY, ADMINISTRATOR, OR EXECUTOR

6. ARE ANY OF THE INDIVIDUALS AT LEFT MEMBERS
OF THE IMMEDIATE FAMILY (Please specify)

7. ARE SPECIAL CLAIM FORMS AVAILABLE?
YES (If Yes, please provide)

NO

8. REMARKS

9a. NAME OF INDIVIDUAL COMPLETING FORM

DD FORM 2840, AUG 2004

b. SIGNATURE

PREVIOUS EDITION IS OBSOLETE.

c. DATE

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