Form DD Form x595 DD Form x595 Claim for Retroactive Stop Loss Payment

CLAIM FOR RETROACTIVE STOP LOSS PAYMENT
(Read Privacy Act Statement and Instructions before completing form.)

OMB No. 0704-####
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The public reporting burden for this collection of information is estimated to average 30 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, 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.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM BY FIRST CLASS MAIL, EMAIL OR
FAX TO THE SERVICE UNDER WHICH YOU SERVED WHILE ON ACTIVE DUTY AT THE ADDRESS LISTED ON THE FOLLOWING PAGE.

PRIVACY ACT STATEMENT
AUTHORITY: Public Law 111-32, Section 310; E.O. 9397.
PRINCIPAL PURPOSE(S): Solicitation of information contained herein may be used as a basis for retroactive stop loss pay
determinations. Your information will be used by the Services, for verification of eligibility and then by the Defense Finance and
Accounting Service for payment of Retroactive Stop Loss payments. The Military Departments describe how your information will be
maintained in their Privacy Act System of Record Notice.
ROUTINE USE(S):

The DoD "Blanket Routine Uses" apply.

DISCLOSURE: Voluntary; however, failure to provide information requested on this form may result in the government's inability to
provide benefits under the stop loss pay program. Your Social Security Number is being requested pursuant to E.O. 9397. The
SSN and other identifying information are needed to pay the proper person, ensure entitlement to benefits, and for tax purposes.

D R A F T
INSTRUCTIONS

PURPOSE.
This form collects information for Military Department programs for Retroactive Stop Loss Special Pay as authorized and
appropriated in Section 310 of Public Law 111-32. This program compensates Service members, including members of the
Reserve components, as well as former and retired members under the jurisdiction of the Secretary who, at any time during the
period beginning on September 11, 2001, and ending on September 30, 2009, served on active duty while the Service member's
enlistment or period of obligated service was extended, or whose eligibility for retirement was suspended pursuant to any provision
of law authorizing the President to extend any period of obligated service, or suspend eligibility for retirement, of a Service member
in time of war or of national emergency declared by Congress or the President. Only Service members who were honorably
discharged from the Service and were under Stop Loss Authority while on Active Duty are eligible to apply for this special payment
program.
GENERAL BACKGROUND STATEMENT.
Under the "Supplemental Appropriations Act, 2009", Public Law 111-32, the Military Departments are authorized to collect the
information needed to certify the claimant's eligibility to collect payment while under Stop Loss Authority. The Military Departments
need this information to accurately determine the time, amount, and taxability of the claim submitted for payment. If the claim is
denied, the claimant can contact the Service they served in to submit their appeal. Final determination on granting benefits under
this program is the responsibility of the Military Departments. You may be provided the opportunity personally to explain, refute, or
clarify any information before a final decision is made. If you made claim to Stop Loss payment under any other Public Law over the
last two years, then you are not eligible to make a claim for the same time period under this Public Law.
CLAIMANT.
If discharged, the Service member must have been honorably discharged. Veterans: The claimant is the veteran or an eligible
recipient of the veteran's estate of a deceased veteran. If claimant is incompetent, please include conservator documentation with
this form. In addition, if payment is being made to the veteran's estate, proper supporting documentation must also be submitted
with this form. Non-submission of this documentation will delay payment.
DOCUMENTATION.
In addition to this form, submit documentation as listed below. The Military Departments may request additional documentation
as necessary.
1. DD Form 214, Certificate of Release or Discharge from Active Duty and/or DD Form 215, Correction to DD Form 214.
2. Personnel record or enlistment or reenlistment document recording original expiration of service date.
3. Approved retirement memorandum or orders establishing retirement prior to actual date of retirement as stipulated on DD Form
214 or DD Form 215.
4. Approved resignation memorandum or transition orders establishing a separation date prior to actual date of separation as
stipulated in DD Form 214 or DD Form 215.
5. Signed documentation or affidavit from knowledgeable officials from the individual's chain of command acknowledging
separation/deployment, etc.
Attachments included (X one)
YES
NO

DD FORM X595 INSTRUCTIONS, 20091020 DRAFT

Adobe Professional 8.0

CLAIM FOR RETROACTIVE STOP LOSS PAYMENT
THIS CLAIM MUST BE FILED BY OCTOBER 21, 2010. Please type or print legibly.
RETURN YOUR CLAIM TO THE SERVICE UNDER WHICH YOU SERVED WHILE ON ACTIVE DUTY:
DEPARTMENT OF THE AIR FORCE:
Active, retired and former Air Force members:
E-mail: [email protected]
Fax: (210) 565-4599 or DSN: 665-4599
Mail: AFPC/DPSOS (Stop Loss Section)
550 C. Street West, Suite 3
Randolph AFB, TX 78150-4713

Reserve component members:
E-mail:
[email protected]
Fax: (478) 327-2215 or DSN 497-2215
Mail: HQ ARPC/DPS (Stop Loss Section)
6760 E. Irvington Place
Denver, CO 80280

DEPARTMENT OF THE ARMY:
It is preferred that applicants submit on-line
applications to the U.S. Army Stop Loss Program
Office, via the web-based, on-line system at
https://www.stoplosspay.army.mil. Alternatively, hard
copy signed and dated applications may be mailed
to:
E-mail: [email protected]
Mail: 5109 Leesburg Pike, Suite 302
Falls Church, VA 22041

U.S. MARINE CORPS:
It is preferred that applicants submit on-line applications to the Marine Corps Stop Loss Program
DEPARTMENT OF THE NAVY:
Office (SLPO), via the web-based, on-line Stop Loss Case Management System (SLCMS) at
the following URL: https://www.manpower.usmc.mil/slcms. Alternatively, hard copy signed and
Commander
dated applications may be mailed to:
Navy Personnel Command
Headquarters U.S. Marine Corps
PERS 832
Manpower and Reserve Affairs MID/SLPO
5720 Integrity Drive
3280 Russell Rd.
Millington,
TN 38055-8320
Quantico VA 22134-5103
Telephone: (901) 874-4437, DSN: 882-4437
SLPO Organizational Mailbox: [email protected]
Email: [email protected]
SLPO toll free phone number: 1-877-242-2830
1. MILITARY MEMBER

2. CLAIMANT (If other than Member)
b. SSN (Last 4
digits)

a. NAME (Last, First, Middle Initial)

3. SERVICE AT TIME OF ACTIVE DUTY (X one)

4. SERVICE STATUS AT START OF STOP LOSS (X one)

ARMY

NAVY

ACTIVE DUTY

AIR FORCE

MARINE CORPS

OTHER SERVICE (Specify)

5. VETERAN'S CURRENT STATUS (X one)
LIVING

DECEASED*

b. SSN (Last 4
digits)

a. NAME (Last, First, Middle Initial)

ANG

IRR

RESERVE

6. VETERAN STATUS (X one)
INCAPACITATED

RETIRED

SEPARATED

* If deceased, attach documentation establishing the beneficiary.
7. CLAIMED STOP LOSS PERIOD**
a. FROM (YYYYMMDD)

**Dates on eligible Active Duty during covered stop loss time periods. If
more than one claim, list each claim separately on one attachment to this
application and submit.

b. TO (YYYYMMDD)

8. CLAIMANT'S MAILING ADDRESS/CONTACT INFORMATION
a. STREET/APARTMENT NUMBER

b. CITY

c. STATE

D R A F T

e. TELEPHONE NUMBER (Include area code)

f. EMAIL ADDRESS

d. 9-DIGIT ZIP CODE

g. STATE OF LEGAL RESIDENCE

9. PAYMENT DISBURSEMENT (X one)
DIRECT DEPOSIT/ELECTRONIC FUNDS TRANSFER

CHECK

10. FINANCIAL INFORMATION
a. BANK NAME

b. ACCOUNT NUMBER

c. BANK ROUTING NUMBER

11. CLAIMANT AUTHORIZATION

I hereby authorize the Military Department under which I served while on Active Duty and other authorized Federal agencies to
obtain any information required including, but not limited to, Internal Revenue Service (IRS), DFAS, etc. This authorization is valid for
one year from the date this form was signed. I understand I have a right to challenge the accuracy and completeness of any
information contained in the report pertaining to my case. I also understand that this information will be treated as privileged and
confidential information. Case files are handled under the procedures for safeguarding records.
I hereby release any individual, including records custodians, any component of the U.S. Government supplying information, from
all liability for damages that may result on account of compliance, or any attempts to comply with this authorization. This release is
binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this
authorization that show my signature are as valid as the original release signed by me.
a. CLAIMANT SIGNATURE (Mandatory)

DD FORM X595, 20091020 DRAFT

b. DATE SIGNED (YYYYMMDD)

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