Form DD Form 397 DD Form 397 Claim Certification and Voucher for Death Gratuity Payme

CLAIM CERTIFICATION AND VOUCHER FOR
DEATH GRATUITY PAYMENT

1. BUREAU VOUCHER NO.

2. D.O. VOUCHER NO.

OMB No.
OMB approval expires

(10 U.S.C. 1475-1480 and regulations pursuant thereto)
Return completed form to the appropriate Service Casualty Office or contact the Service Pay or Finance Office for direction on where to
submit your completed form. DO NOT return your form to the address in the paragraph below.
The public reporting burden for this collection of information is estimated to average XX 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, Information Management Division, 1155 Defense Pentagon,
Washington, DC 20301-1155 (XXXX-XXXX). 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.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Sections 1475-1480, and E.O. 9397.
PRINCIPAL PURPOSE(S): To record the name and address of the designated beneficiary(ies) or next-of-kin eligible to receive the death gratuity
payment for the deceased service member, in accordance with a finding by the Secretary of the Service concerned, and to maintain a record of the
disbursement of these benefits.
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: The DoD "Blanket
Routine Uses" set forth at the beginning of DoD's compilation of systems of records notices apply to this system.
DISCLOSURE: Disclosure is voluntary; however, failure to provide the requested information may impede or delay the processing of this claim.
NOTE: Penalties for presenting false claims or making false statements in connection with claims may include criminal fines or imprisonment of up to
5 years per incident and civil fines in excess of $10,000 (False Claims Act, as amended, 31 U.S.C. Sections 3729-3733 and 18 U.S.C. Sections 287
and 1001).
3. APPROPRIATION SYMBOL AND TITLE
4. PAID BY

5. NAME AND ADDRESS OF PAYEE (Number and Street, City, State and ZIP Code)

6. SERVICE MEMBER (Last name - First name - Middle initial)

7. SOCIAL SECURITY NO.

9. PLACE OF DEATH

10. DATE OF DEATH

8. GRADE
11. DUE PAYEE

12. CERTIFICATE OF PAYEE (Place an "X" in one of the following boxes, according to your relationship to the decedent)
I certify that I have not received gratuity pay; that I am:
a.

HIS WIDOW

HER WIDOWER. (Complete only Block 14a and have Block 14 signed by two certifying witnesses.)

b. A CHILD OF THE DECEDENT; THAT THERE IS NO WIDOW(ER) SURVIVING; THAT THE CONTENTS OF BLOCK 13 ARE ACCURATE AS
SHOWN. (If payee is a minor at time of preparation of this form, Block 14a must be completed by the duly appointed guardian and documentary proof
of guardianship furnished. Complete Blocks 13 and 14a and have Block 14 signed by two certifying witnesses.)
c. THE
FATHER
MOTHER
BROTHER
SISTER OF THE DECEDENT;
THAT THERE IS NO WIDOW(ER), OR CHILD SURVIVING. (Complete Blocks 13 and 14a and have Block 14 signed by two certifying witnesses.)
d. OTHER

13. CHILDREN OF THE DECEDENT (If none, so state. Attach additional page if more space is needed)
a. NAME (Last, First, Middle Initial)

b. ADDRESS (Include ZIP Code)

NEEDS DD 67
14. CERTIFICATE OF WITNESSES TO SIGNATURE OF PAYEE (Two witnesses are required)
I certify that I am personally well acquainted with the above-named payee, that I have read the
above statement which was signed in my presence, and that said statement is true to the best of my
knowledge and belief.

a. SIGNATURE OF PAYEE (Must be affixed
in the presence of two witnesses)

b. FIRST WITNESS
(1) SIGNATURE

c. SECOND WITNESS
(1) SIGNATURE

d. ADDRESS OF PAYEE (Include ZIP Code)

(2) ADDRESS (Include ZIP Code)

(2) ADDRESS (Include ZIP Code)

15. ADMINISTRATIVE STATEMENT
The above-named payee is authorized to receive gratuity pay due to the death of the decedent; and has been so designated by the decedent.
a. TYPED NAME

b. TITLE

c. SIGNATURE

d. DATE (YYYYMMDD)

16. PAYMENT
a. PAID BY CHECK DRAWN IN FAVOR OF PAYEE NAMED ABOVE
(1) CHECK NUMBER
(2) AMOUNT OF CHECK (3) DATE OF CHECK

DD FORM 397, 20080715 DRAFT

b. ELECTRONIC FUNDS TRANSFER (EFT)
(1) BANKING INSTITUTION
(2) ACCOUNT NUMBER (3) ROUTING NUMBER

PREVIOUS EDITION IS OBSOLETE.

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