Form DD Form 2761 DD Form 2761 Personal Check Cashing Agreement

PERSONAL

CHECK CASHING

OMB No. 0730-0005
OMB approval expires
Feb 28, 2007

AGREEMENT

The publicreportingburdenforthis collectionof IntonnationIs estimatedto
30 minutes response.Includingthe timeforreviewingInstructions.searchingexistingdata sources,gathering
and maintairongthe data needed, and completingand reviewingthe collection infonmation. end commentsregari:ling
this burdenestimateor any otheraspect of this collectionof Information,
Includingsuggestionsforreducingthe btrden. to the Departmentof Defense,ExecutiveServicesDirectorate!07).
Respondentsshouldbe awarethat notwithstandingany otherprovisionof
law. no person shaD be subject to any penalty for failing to comply with a collection of information n does not display a curenUy valid OMS control number.

PLEASE DO NOT RETURNYOUR FORM TO THE ABOVEORGANIZATION.RETURNCOMPLETED FORM TO THE ADDRESS OF THE AGENCY
WHICH PROVIDED THIS FORM,
PRIVACY ACT STATEMENT

AUTHORITY:

31 U.S.C. Section 3342. E.O. 9397, and DoD Financial Management Regulation (DoDFMR) 7000.14-R, Volume 5, Chapter 4.

PRINCIPAL PURPOSES: This form is designed exclusively to help overseas and afloat DoD disbursing activities, expedite the collection
process of dishonored checks overseas and afloat.
ROUTINE USES: The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act of
1974, as amended. It may also be disclosed outside of the Department of Defense to Federal, state, or local government agencies, which have
identified a need to know, for the purpose(s) identified in the DoD Blanket Routine Uses as published in the Federal Register.
DtSCLOSURE:

Voluntary; however, failure to provide the requested information may result in refusal to cash personal checks.

PLEASE PRINT OR TYPE ALL INFORMATION.
1. NAME (Last, First, Middle)

2. SOCIAL SECURITY NUMBER

3. ORGANIZATION/LOCATION

4. RANK/GRADE
5. DUTY TELEPHONE NUMBER
(Include Area Code)

6. BRANCH OF SERVICE

7. SUPERVISOR'S NAME (Last, First, Middle Initial)

8. SUPERVISOR'S TELEPHONE NUMBER
(Include Area Code)

9. HOME ADDRESS (Street, Apartment Number, City, State, ZIP Code)

10. HOME TELEPHONE NUMBER

11. DRIVER'S LICENSE NUMBER

12. DRIVER'S LICENSE STATE

(Include Area Code)

POWER OF ATTORNEY
I desire to execute
individual(s)

a power of attorney

and I appoint and by these presents

my true and lawful attomey(s)-in-fact

to draw, make, endorse,

do make, constitute

and cash personal

and appoint the below listed

checks

drawn upon any account

which I may have as sole or joint owner.
heirs, legal and personal representatives

Any act performed hereunder for me or from my account shall be binding on me, my
and assigns. Transactions under this authority shall be in my name and all

endorsements
and instruments
designation "Attomey-in-Fact".

by my attorney

executed

shall contain my name, followed

13. AUTHORIZED AGENT

14. AUTHORIZED AGENT

15. AUTHORIZED AGENT

16. AUTHORIZED AGENT

by that of my attomey

and the

"In consideration
of the extension of the privilege to have personal checks cashed by a Department of Defense financel
disbursing officer, I hereby freely and voluntarily consent to the immediate collection from my current pay, without prior notice or
prior opportunity to be heard, the face value of any check cashed by myself or my authorized agents, plus any charges
assessed against the govemment
by a financial institution, in the event such instrument is dishonored and retumed for
insufficient funds or closed accounts."
18. DATE

17. REQUESTOR'S SIGNATURE

DD FORM2761, FEB 2004

--

PREVIOUSEDITIONIS OBSOLETE.

LOCAL REPRODUCTION AUTHORIZED.

PAY ADJUSTMENT
1. MEMBERIEMPLOYEENME

fLast, First, Middle)

5. PAY GRADENUMBER

NOTE: If individualhas been transferred.forwardthis

AUTHORIZATION
2. SSN

authorizationto the officercurrentlymaintaining
the individual'spay record.
3. RANK/GRADE
4. BRANCHOF SERVICE

6. AMOUNT

7. APPROPRIATIONDATA

8. FROM

9. NAMEOF ACCOUNTABLEDISBURSINGOFFICER
(D.O.)
10. D.O. SYMBOL

12. TO

11. G.A.O.EXCEPTION
CODE

13. YOU ARE HEREBYAUTHORIZEDTO DEDUCT
THE AMOUNTOF $
FROMTHE ACCOUNTOF THE ABOVE NAMED
INDMDUAL.

14. EXPLANATIONANDIORREASONFOR ADJUSTMENT

I CERTIFY that this collection is the result of dishonored personal checks cashed by the cited individual for the amounts
stated. The individual has consented in writing, that in consideration for cashing the individual's check(s) the amount of any
check returned unpaid for any reason, plus any charges assessed against the govemment by a financial institution, may be
collected from the individual's pay.
15. FROM

16. DISBURSINGOFFICER
a. NAME (Last,First. Middle Initial)

b. RANK/GRADE c. SIGNATURE

I CERTIFY that the adjustment indicated above has been entered on the above-named individual's Pay Record.
(If adjustmenthas not been entered,give explanationin the spaceprovidedabove.)
17. TO

18. PAYROLLOFFICER
a. NAME (Last,First, MiddleInitial)(Typeor Print)

19. PAYROLLDSSN

21. SIGNATURE

DD FORM 2761 (BACK), FEB 2004

20. DATE

b. RANK/GRADE