Form DD Form 2789 DD Form 2789 Waiver/Remission of Indebtedness Application

OMB No. 0730-0009
OMB approval expires
Nov 30, 2008

WAIVER/REMISSION OF INDEBTEDNESS APPLICATION
(If more space is needed, continue on separate sheet(s). Identify each item by number.)

The public reporting burden for this collection of information is estimated to average 2 hours 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 (0730-0009). 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.
SEPARATED MILITARY OR FORMER CIVILIAN EMPLOYEES, RETURN COMPLETED FORM TO: DFAS-IN, DEPT. 3300 (WAIVER/REMISSION),
8899 EAST 56TH STREET, INDIANAPOLIS, IN 46249-3300.
ACTIVE DUTY MILITARY, GUARD/RESERVE, RETIRED OR ANNUITANT PAY RECIPIENTS, CIVILIAN EMPLOYEES, RETURN COMPLETED
FORM TO THE ADDRESS LISTED ON THE DEBT NOTIFICATION LETTER FOR COMPLETION OF BACK SIDE.
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9397 (SSN).
PRINCIPAL PURPOSE: To be used by civilian employees (current, former, or retired) and military members (active, separated, or retired), and
annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances, and expense reimbursement or
allowances for travel, transportation, and relocation; or in the case of enlisted members, remission of these debts.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the PA, this information may be disclosed to
the Department of Justice or to commercial credit agencies, whenever a financial status report is requested by the Department of Defense (DoD) for
use in administering the Federal Claims Collection Act. It may also be disclosed for any of the blanket routine uses as published in the Federal
Register at the beginning of the DFAS compilation of PA system notices.
DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data, including your Social Security Number, may prevent
consideration of the claim.
1. TYPE OF CLAIM (X one)
WAIVER
REMISSION
Authority for granting waiver: Active/Retired Military - 10 U.S.C. 2774; National Guard - 32 U.S.C. 716; Civilian - 5 U.S.C. 5584;
Annuitant - 10 U.S.C. 1442/1453. Remission: Army - 10 U.S.C. 4837; Navy - 10 U.S.C. 6161; Air Force - 10 U.S.C. 9837.
Note: Remission generally is applicable for active duty enlisted personnel only, see DoDFMR, Volume 7A.
2. NAME (Last, First, Middle Initial)
5. AGENCY/SERVICE
ARMY

OTHER (Specify)

SECTION I - CIVILIAN/MILITARY/RETIREE/ANNUITANT INFORMATION
3. RANK/GRADE
4. SOCIAL SECURITY NUMBER
6. STATUS (X applicable block and provide date (YYYYMMDD) for end of enlistment period (EOE),
retirement (DOR), separation (DOS), or service computation date (SCD), as appropriate.)

NAVY

ACTIVE

EOE:

SEPARATED

AIR FORCE

GUARD/RESERVE

EOE:

DOD CIVILIAN SCD:

MARINE CORPS

RETIRED

DOR:

ANNUITANT

8. PLACE OF ASSIGNMENT OR
EMPLOYMENT

a. WORK

7. CURRENT COMPLETE MAILING ADDRESS (Street, City, State,
ZIP Code)

DOS:

9. TELEPHONE (Include DSN or area code)
b. HOME
c. E-MAIL ADDRESS:

10. TYPE OF DEBT OR PAY AND ALLOWANCE ERRONEOUSLY PAID

11. GROSS DEBT AMOUNT

12. STATE THE DATE AND HOW YOU FIRST BECAME AWARE OF DEBT OR ERRONEOUS PAYMENT. (Attach notification, if available.)
13. IF YOU WERE AWARE OF DEBT OR ERRONEOUS PAYMENT, EXPLAIN THE ACTIONS YOU TOOK TO CORRECT SITUATION.

14. REASON FOR REQUESTING WAIVER/REMISSION AND WHY YOU FEEL IT SHOULD BE APPROVED (Financial hardship applies ONLY to
REMISSION and if claimed, a financial statement must be attached.)

15. FOR ANNUITANTS, PROVIDE NAME, SSN AND DATE DECEASED OF MILITARY MEMBER/SPONSOR.
16. ATTACH COPIES OF ALL PERTINENT DOCUMENTS (Such as Request for BAH, Statement of Service, Separation Worksheet,
DD Form 214, Travel Voucher, Notification of Personnel Action). (If not available, please explain.)
17.a. IF MILITARY OR CIVILIAN, DID YOU RECEIVE LEAVE AND EARNINGS STATEMENT(S)?
b. IF MILITARY OR CIVILIAN, DID YOU REQUEST THEM ON EMSS/MYPAY?
c. IF RETIREE OR ANNUITANT, DID YOU RECEIVE AN ACCOUNT STATEMENT?
d. IF RETIREE OR ANNUITANT, DID YOU REVIEW THEM?

YES

NO

YES
YES

NO
NO

YES

NO

(If answer to a. or c. is Yes, attach a copy of statement covering before, during, and after period. If No, explain why.)
18. HAVE YOU FILED FOR A CORRECTION OF MILITARY RECORDS?
NO
YES
19. I certify the above statements are true and correct to the best of my knowledge. The information presented may be referred to the
appropriate investigating office for verification. I understand the penalty for a false claim is a maximum fine of $10,000 or a maximum
imprisonment of 5 years, or both.
a. SIGNATURE

DD FORM 2789, MAY 2008

b. JOB TITLE/CAREER FIELD

PREVIOUS EDITION IS OBSOLETE.

c. DATE SIGNED

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20. COMMANDER'S ENDORSEMENT (Required for Navy active duty and reserves, others optional. Use separate sheet of paper if needed.)

21. RECOMMENDATION:
APPROVE
22a. COMMANDER'S SIGNATURE

PARTIAL

$

DENY

RECOMMEND COLLECTION RATE

$

b. DATE SIGNED

SECTION II - REPORT OF INVESTIGATION
To be completed and signed by appropriate payroll/travel office. (Not applicable for retirees, annuitants, or out-of-service military members.)
23. INFORMATION ON DEBT OR ERRONEOUS PAYMENT(S)
a. GROSS DEBT AMOUNT

b. TYPE(S) OF PAYMENT(S)

c. DATE(S) OF PAYMENT(S)

YES NO

d. (X and complete as applicable)

(5) DATE THE DEBT WAS DISCOVERED

(1) HAS THE DEBT BEEN VALIDATED?
(2) HAS THE DEBT BEEN POSTED TO THE DEBTOR'S RECORDS?

(6) NAVY ONLY: AMOUNT UNCOLLECTED AS OF

(3) REMISSION: HAS THE COLLECTION ACTION BEEN SUSPENDED?

DATE OF THE COMMANDER'S SIGNATURE:

(4) WAIVER: HAS FINANCE OFFICE SUSPENDED COLLECTION IAW DODFMR, VOL. 5, CH. 31?

$

24. A DEBT COMPUTATION MUST ACCOMPANY THIS APPLICATION. It must include dates of erroneous payments, what was paid (broken down
by entitlements), what should have been paid, and the difference. The total debt must equal the debt posted to the debtor's record. Indicate any
entitlements or credits used to offset the debt. This application will be returned without action unless the computation is included.
a. ENTITLEMENT

b. DATE(S)

c. WAS PAID

d. SHOULD HAVE BEEN PAID

e. DIFFERENCE

0.00
0.00
0.00
0.00
25. DETAILED STATEMENT OF HOW AND WHY ERROR OCCURRED.

26. IS THERE ANY INDICATION OF FRAUD, MISREPRESENTATION, FAULT, OR LACK OF GOOD FAITH ON THE PART OF THE CLAIMANT?
NO
YES (Explain)
27. STATEMENT AS TO WHETHER OR NOT THE CLAIMANT KNEW OR SHOULD HAVE BEEN AWARE OF RECEIVING AN ERRONEOUS
PAYMENT. (Furnish facts and circumstances to support answer, state whether claimant received documents, and provide copies, if
available. Use a separate sheet of paper if additional space is required.)

28. REMARKS (Attach a separate sheet of paper, if needed.)

29. RECOMMENDATION:

APPROVE

PARTIAL

$

DENY

30. DESIGNATED FINANCIAL AGENT
a. SIGNATURE

31a. COMPLETE UNIT MAILING ADDRESS

b. TITLE

c. DATE SIGNED

b. POINT OF CONTACT NAME
c. TELEPHONE (DSN)

e. ADSN/DSSN/UIC

DD FORM 2789 (BACK), MAY 2008

d. FAX NUMBER

f. E-MAIL ADDRESS

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