Form DD Form 2828 DD Form 2828 Physician Certificate for Child Annuitant

OMB No. 0730-0011
OMB approval expires

PHYSICIAN CERTIFICATE FOR CHILD ANNUITANT

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 (0730-0011). 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: Defense Finance and
Accounting Service, US Military Annuitant Pay, PO Box 7131, London, KY 40742-7131

PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C., Chapters 53, 61, 63, 65, 67, 69, 71, 73, 74; 10 U.S.C. Sec. 1059, and 1408(h); 38
U.S.C. Sec. 1311 and 1313; Pub. L. 92-425; Pub. L. 102-484 Sec. 653; Pub. L. 103-160 Sec. 554 and 1058; Pub. L. 105-261, Sec. 570; DoDI 1342.24,
Transitional Compensation for Abused Dependents; DoD Financial Management Regulation 7000.14-R, Volume 7B and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To obtain certification that a member's child is unmarried and incapable of self-support because of mental and/or physical
incapacitation so annuity payments can be continude according to the law. Applicable SORNs: T7247b.
ROUTINE USE(S): Certain "Blanket Routine Uses" for all DoD maintained systems of records have been established that are applicable to every
record system maintained within the Department of Defense, unless specifically stated otherwise within the particular record system notice. These
additional routine uses of the records are published only once in each DoD Component's Preamble in the interest of simplicity, economy and to avoid
redundancy.
DISCLOSURE: Voluntary; however, if certification is not received, eligibility of annuitant cannot be determined and annuity payments will be stopped.
The Social Security Number is required to identify the correct member/annuitant for payment purposes.
NOTE: 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 (18 U.S.C. 1001).
1. DECEASED MEMBER'S 2. ANNUITANT'S NAME (Last, First, Middle Initial)
SSN

3. DATE OF BIRTH
(YYYYMMDD)

5. BRIEF DESCRIPTION OF MEDICAL/PSYCHIATRIC DIAGNOSIS

6. DATE CONDITION BEGAN (YYYYMMDD)

N E E D S

D D

4. ANNUITANT'S SSN

6 7

7. PHYSICIAN'S STATEMENT
a. I have attended the patient for

years

months.

b. I last examined the patient on:
c. In my opinion the patient is (X one or both)
(1) Incapable of self-support for the period
(2) Incapable of handling his/her own financial affairs for the period
d. In my opinion the incapacity is (X one)

permanent

temporary.

If temporary, expected recovery date (YYYYMMDD)

e. I am a licensed
physician or practitioner authorized to practice medicine in the state of
psychiatrist authorized to practice medicine in the state of
8. I HEREBY CERTIFY THAT THE INFORMATION ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE.
a. PRINT PHYSICIAN'S NAME (Last, First, Middle Initial)
b. ADDRESS (Include ZIP Code)

c. SIGNATURE

DD FORM 2828, 20110106 DRAFT

d. DATE (YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

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