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

STATEMENT OF CLAIMANT REQUESTING REPLACEMENT CHECK

OMB No. 0730-0002

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, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (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 IT TO THE ADDRESS OF THE AGENCY WHO PROVIDED THIS FORM.

PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; Department of Defense Financial Management Regulation (DoDFMR) 7000.14-R, Volume 5;
31 U.S.C. Sections 3511, 3512, and 3513; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To be used by intended recipients of U.S. Treasury checks to request a replacement for a lost, stolen, destroyed, or
mutilated check, or one canceled due to limited payability. Disbursing Offices will use the information to make the determination to issue a replacement
check based on the information provided, and for canceling the original check. The information will also verify a proper mailing address for the claimant.
Applicable SORN: T7901 (http://dpclo.defense.gov/privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6287/t7901.aspx).
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ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the Privacy Act, as amended, this information may
be disclosed to the Department of Justice of 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.
(http://dpclo.defense.gov/privacy/SORNs/component/dfas/preamble.html)
DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data may prevent issuance of a replacement check. The Social
Security Number is requested to verify the claimant and certify what happened to the original check issued by the government.

N E E D S D D 6 7

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."
2. SSN/EIN

1. PAYEE (Show business name or financial organization, if applicable)

3. TELEPHONE NUMBER (Include area code)

4. E-MAIL ADDRESS

5. ACCOUNT TO BE CREDITED IF ITEM 1 IS A FINANCIAL ORGANIZATION

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

8. PURPOSE FOR WHICH CHECK WAS ISSUED (X as applicable)
a. REGULAR PAY

b. TRAVEL PAY

7. CORRECT MAILING ADDRESS (If different from Item 6)

9. DATE DUE (Approximate)

c. VENDOR PAY

d. OTHER
(Specify)

(1) LOST

(3) DESTROYED

(2) STOLEN

(4) MUTILATED

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

b. RECEIVED,
BUT:

(5) CANCELED (LIMITED
PAYABILITY)

11. 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 replacement 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 replacement 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
replacement checks, including interest and administrative costs.
12. SIGNATURE OF PAYEE (Or payee representative)

13. DATE

14. SIGNATURE OF CO-PAYEE (If applicable)

15. DATE

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

b. DATE OF CHECK

c. CHECK AMOUNT

d. ISSUING DSSN

e. VOUCHER NUMBER

17. DO REMARKS

DD FORM 2660, 20140327 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional X

INSTRUCTIONS FOR COMPLETING STATEMENT OF CLAIMANT REQUESTING REPLACEMENT CHECK

1. PAYEE

Payee name, business name or financial organization.

2. PAYEE’S SSN/EIN

Payee’s SSN (for individual) or EIN (for business).

3. TELEPHONE NUMBER

Payee Telephone Number.

4. E-MAIL ADDRESS

Payee e-mail address.

5. ACCOUNT TO BE
CREDITED IF ITEM 1 IS A
FINANCIAL
ORGANIZATION

Enter account number to have been credited.

6. ADDRESS TO WHICH
CHECK WAS MAILED

Address on file.

7. CORRECT MAILING
ADDRESS

New Address.

N E E D S

8. PURPOSE FOR WHICH
CHECK WAS ISSUED

a.
b.
c.
d.

D D 6 7

REGULAR PAY
TRAVEL PAY
VENDOR PAY
OTHER (specify what type of pay)

9. DUE DATE

Date check was due to arrive.

10. CHECK WAS:

X as applicable:
a. NOT RECEIVED
b. RECEIVED BUT:
(1) LOST
(2) STOLEN
(3) DESTROYED
(4) MUTILATED
(5) CANCELED (LIMITED PAYABILITY)

11. WAS CHECK ENDORSED?

Answer Yes or No.

12. SIGNATURE OF PAYEE

Signature of the Payee or payee representative.

13. DATE

Self Explanatory

14. SIGNATURE OF CO-PAYEE

Signature of Co-Payee (if applicable).

15. DATE

Self Explanatory.

16. CHECK DATA
16a. CHECK NUMBER
16b. DATE OF CHECK
16c. CHECK AMOUNT
16d. ISSUING DSSN
16e. VOUCHER NUMBER

For Disbursing Office Use.

17. DO REMARKS
DD FORM 2660 (BACK), 20140327 DRAFT