Form DD Form X683 DD Form X683 Application for Surrogate Association for DoD Self-Servi

APPLICATION FOR SURROGATE ASSOCIATION FOR DOD SELF-SERVICE (DS) LOGON

OMB No. 0704-0559
OMB approval expires

The public reporting burden for this collection of information is estimated to average 2 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 at [email protected] (0704-0559). 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 ADDRESS. RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL IDENTIFICATION
SYSTEM WORK STATION.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Manual 1341.02, Volume 1, DoD Identity
Management: DoD Self-Service (DS) Logon Program and Credential.
PRINCIPAL PURPOSE(S): To establish a Defense Enrollment Eligibility Reporting System (DEERS) record and surrogate association
for issuance of a DoD Self-Service (DS) Logon. A surrogate may be established: (1) As the custodian of an unmarried minor child(ren)
of a deceased Service member who is under age 18, who is at least 18 but under 23 and attending school full-time, or who is
incapacitated. (2) As the agent of an incapacitated dependent (e.g., spouse, parent). (3) As the agent of a wounded, ill, or mentally
incompetent Service member.
ROUTINE USE(S): To the Social Security Administration, for the purpose of verifying the surrogate's identity. For a complete list of
DEERS routine uses, visit:
http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleVie/tabid/6797/Article/570690/dmdc-020dod.aspx.
Information may also be used and disclosed in accordance with 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, which
incorporates the DoD "Blanket Routine Uses" published at http://dpcld.defense.gov/privacy/SORNsIndex/BlanketRoutineUses.aspx.
DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a DS Logon.
SECTION I - SURROGATE INFORMATION
2. GENDER
(Select)

1. SURROGATE FULL NAME (Last, First, Middle)

5. HOME ADDRESS

3. DATE OF BIRTH
(YYYYMMDD)

4. SSN or DoD ID NUMBER

NEEDS DD67

a. STREET ADDRESS (Include Apartment Number)

b. CITY

c. STATE d. ZIP CODE

e. COUNTRY

7. TELEPHONE NUMBER (Include
Area Code)

6. PRIMARY EMAIL ADDRESS

SECTION II - BENEFICIARY INFORMATION
9. BENEFICIARY SSN or DoD ID NUMBER

8. BENEFICIARY FULL NAME (Last, First, Middle)

10.a. SPONSOR SSN or DoD ID NUMBER (If Beneficiary is not the Sponsor)

10.b. SPONSOR SSN or DoD ID NUMBER (If Beneficiary has two Sponsors)

11. SURROGATE ASSOCIATION ON BEHALF OF A BENEFICIARY (X one or more, as appropriate)

Financial Agent (FA). Named by the beneficiary to assist the beneficiary with specific financial matters. If the beneficiary is a
dependent, the dependent must be over age 18, eligible for DoD benefits in accordance with DoD Manual 1000.13, Volume 2, and
competent to consent to contract.
Legal Agent (LA). Named by the beneficiary to assist the beneficiary with legal matters. If the beneficiary is a dependent, the
dependent must be over age 18, eligible for DoD benefits in accordance with DoD Manual 1000.13, Volume 2, and competent to
consent to contract.
Caregiver (CG). Named by the beneficiary to assist the beneficiary with general health care requirements (example, viewing
general health care-related information, scheduling appointments, refilling prescriptions, and tracking medical expenses) but does
not make health care decisions. If the beneficiary is a dependent, the dependent must be over age 18, eligible for DoD benefits in
accordance with DoD Manual 1000.13, Volume 2, and competent to consent to contract.
Health Care Agent (HA). Named by the beneficiary (the patient) in a Durable Power of Attorney for Health Care document
executed before the beneficiary loses decision making ability. If the beneficiary is a dependent, the dependent must be over age
18, eligible for DoD benefits in accordance with DoD Manual 1000.13, Volume 2, and competent to consent to contract.
Legal Guardian (LG). Appointed by a court of competent jurisdiction in the United States (or jurisdiction of the United States) to
make decisions for the beneficiary.
Special Guardian (SG). Appointed by a court of competent jurisdiction in the United States (or jurisdiction of the United States)
for the specific purpose of making health care-related decisions for the beneficiary.

DD FORM X683, 20150519 DRAFT

Adobe Designer 9.0

12. START DATE OF SURROGACY (YYYYMMDD)

13. END DATE OF SURROGACY (YYYYMMDD)

14. SURROGATE SIGNATURE

15. DATE SIGNED

16. BENEFICIARY SIGNATURE

17. DATE SIGNED

SECTION III - CERTIFYING OFFICIAL INFORMATION
To be completed by a SJA, local JAG, or attorney, or by the Service Project Office. Required if establishing a Surrogate association on
behalf of (1) a minor child (under age 18); (2) an incapacitated beneficiary; (3) a beneficiary to establish a Health Care Agent Surrogate
association (must be accompanied by Durable Power of Attorney for Health Care); or (4) a beneficiary to establish a Legal Guardian or a
Special Guardian Surrogate association (must be accompanied by court document).
18. CERTIFYING OFFICIAL FULL NAME (Last, First, Middle)

20. CERTIFYING OFFICIAL EMAIL ADDRESS

19. CERTIFYING OFFICIAL TELEPHONE
NUMBER (Include Area Code)

21. CERTIFYING OFFICIAL ADDRESS (Include ZIP Code)

NEEDS DD67

22. CERTIFICATION (X as applicable)

This is to certify that a Durable Power of Attorney for Health Care has been reviewed and authorizes establishment of a Health
Care Surrogate association. The Durable Power of Attorney for Health Care document is attached.
This is to certify that a court document from a court of competent jurisdiction in the United States (or possession of the United
States) has been reviewed and authorizes establishment of a Legal Guardian or a Special Guardian Surrogate association. The
court document is attached.
23. CERTIFYING OFFICIAL SIGNATURE

DD FORM X683, 20150519 DRAFT

24. DATE SIGNED