Form DD Form 2790 DD Form 2790 Custodianship certificate to Support Claim on Behalf of

OMB No. 0730-0010
OMB approval expires
Nov 30, 2008

CUSTODIANSHIP CERTIFICATE TO SUPPORT CLAIM ON BEHALF OF
MINOR CHILDREN OF DECEASED MEMBERS OF THE ARMED FORCES

The public reporting burden for this collection of information is estimated to average 12 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 (0730-0010). 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 SEND YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO:
Defense Finance and Accounting Service, US Military Annuitant Pay, PO Box 7131, London, KY 40742-7131
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C., Chapter 73; and E.O. 9397.
PRINCIPAL PURPOSE(S): This information is required to identify the custodian of an unmarried minor child(ren), incapacitated child, or child at
least 18 but under 22 who is attending school and is a child of a deceased military member. The Defense Finance and Accounting Service
(DFAS) requires this information to pay or release Survivor Benefit Plan (SBP), and Reserve Component Survivor Benefit Plan (RCSBP) funds
and/or arrears of retired pay for the benefit of the children.
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: to the Internal
Revenue Service, the Department of Veterans Affairs, or trustees or guardians of survivors (children). It may also be disclosed for any of the
"Blanket Routine Uses" as published at the beginning of the DFAS compilation of systems of record notices.
DISCLOSURE: Voluntary; however, if DFAS does not receive this information it may result in non-payment of annuity.
1. MEMBER'S NAME (Last, First, Middle)

2. SSN

3. CHILD(REN) IN CUSTODY
FULL NAME (Last, First, Middle)
a.

SSN
b.

DATE OF BIRTH
c.

RELATIONSHIP TO MEMBER
d.

4. CUSTODIAN'S RELATIONSHIP TO ABOVE CHILD(REN)

5. CERTIFICATION (X as applicable)
This is to certify that the above named child(ren) is an (are) unmarried minor child(ren) of a deceased military member.
This is to certify that the above named child(ren) is (are) at least 18 but under 22 attending a school, technical or vocational
institute, junior college, university or comparable recognized educational institution.
This is to certify that the above named child(ren) is (are) in my care and is incapable of self-support because of a mental or
physical incapacity incurred before his/her 18th birthday or incurred before age 22 during a full-time course of study or training.
A physician's statement attesting the date and extent of incapacity is attached.
I further certify that no legal fiduciary appointment is contemplated on behalf of the child(ren) listed above and that all funds received will
be used for their care and benefit. Also, I will immediately notify Defense Finance and Accounting Service, US Military Annuitant Pay,
PO Box 7131, London, KY 40742-7131, if the status of (any of) the child(ren) is terminated for any reason whatsoever.
WARNING: The penalty for presenting false claims or making false statements in connection with claims is a fine of not more than $10,000 or
imprisonment for not more than 5 years, or both (Act of June 25, 1948, 18 U.S.C. 287, 1001).
a. PRINTED NAME OF CUSTODIAN
(Last, First, Middle Initial)
d. ADDRESS
STREET

b. SIGNATURE OF CUSTODIAN

CITY

c. DATE SIGNED

STATE

ZIP CODE

6. REMARKS

DD FORM 2790, NOV 2005

PREVIOUS EDITION IS OBSOLETE.

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