Form DD Form 2660 DD Form 2660 Statement of Claimant Requesting Recertified Check

OMB No. 0730-0002
OMB approval expires

STATEMENT OF CLAIMANT REQUESTING RECERTIFIED CHECK

The public reporting burden for this collection of information is estimated to average 5 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 (0730-0002). 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 TO THE ADDRESS OF THE AGENCY WHO PROVIDED
THIS FORM.

PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 9397; 31 C.F.R. Sections 245 and 248; and DoDFMR 7000.14-R, Vol. 5., Chapter 8.
PRINCIPAL PURPOSE(S): To be used by active and retired military members, and current and former civilian employees, to request a recertified
check for a lost, stolen, destroyed or mutilated check. Disbursing Offices will use the information to make the determination to reissue a recertified
check, based on the information provided, and for canceling the original check. The information will also verify a proper mailing address for the
claimant.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the Privacy Act (PA), as amended, this
information may be disclosed to the Department of Justice or U.S. Treasury for law enforcement purposes. It may also be disclosed for any of the
blanket routine uses as published in the Federal Register at the beginning of the DoD compilation of PA system notices.
DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data may prevent issuance of a recertified check.
WARNING: Title 18, Sec 287, US Code: "Whoever makes or presents to any person or officer in the civil, military, or naval service of the United
States, or to any department or agency thereof, any claim upon or against the United States, or any department or agency thereof, knowing such claim
to be false, fictitious, or fraudulent, shall be imprisoned not more than five years and shall be subject to a fine in the amount provided in this title."
1. PAYEE (Show business name or financial organization, if applicable)

2. SSN (Or employee identification number)

3. CO-PAYEE TO BE CREDITED IF ITEM 1 IS A FINANCIAL ORGANIZATION

4. ADDRESS TO WHICH CHECK WAS MAILED (Include 9-digit ZIP Code)

5. CORRECT MAILING ADDRESS (If different from Item 4)

D R A F T
7. DATE DUE
(Approximate)

6. PURPOSE FOR WHICH CHECK WAS ISSUED (X as applicable)
d. OTHER (Specify)
a. REGULAR PAY

b. TRAVEL PAY

c. VENDOR PAY

8. CHECK WAS: (X as applicable)
a. NOT RECEIVED

b. RECEIVED, BUT WAS:

(1) LOST

(2) STOLEN

(3) DESTROYED

(4) MUTILATED

9. WAS CHECK ENDORSED? (X one)
a. YES

b. NO

CERTIFICATION
I certify that I (we) have in no way benefitted from the proceeds of the above check, and do hereby request a recertified check be issued to me. I
further certify that if I recover the original check, I will not negotiate it but will immediately return it to the Disbursing Office. I fully understand that
negotiation of both the original and recertified check constitutes a fraudulent act against the United States Government and as such is subject to
punishment as provided by law. I further consent to immediate recoupment from future pay and allowances due me if I negotiate both the original and
recertified checks, including interest and administrative costs.
10. SIGNATURE OF PAYEE (Or payee representative)

11. DATE

12. SIGNATURE OF CO-PAYEE/THIRD PARTY 13. DATE

FOR DISBURSING OFFICE USE
14. CHECK DATA
a. CHECK NUMBER

b. DATE OF CHECK

c. CHECK AMOUNT

d. ISSUING DSSN

e. VOUCHER NUMBER

15. DO REMARKS

DD FORM 2660, 20100803 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Reset

Adobe Professional 8.0