Form DD Form 2826 DD Form 2826 Trustee Report

OMB No. 0730-0012
OMB approval expires

TRUSTEE REPORT

The public reporting burden for this collection of information is estimated to average 1 hour 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, Directives Division, Information Management Branch, 4800
Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0730-0012). 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 REPORT TO:
Defense Finance and Accounting Service
Retired Pay Department
P.O. Box 998021
Cleveland, OH 44199-8021

PRIVACY ACT STATEMENT
AUTHORITY: 27 USC Chapter 11, Section 602, "Payments: Designation of Person to Receive Amounts Due, 7000.14,Volume 7B, "Department of Defense Financial Management Regulation (FMR)
Chapter 16, "Physical or Mental Incapacitation," and Executive Order 9397, "Numbering System for Federal Accounts Relating to Individual Persons."
PRINCIPAL PURPOSE: To report on the administration of the funds received on behalf of a mentally incompetent member of the uniformed services.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records, or information contained therein, may specifically be disclosed outside the
DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: to Internal Revenue Service for tax administration; Department of Veterans Affairs for pay entitlements; Social Security Administration for
pay entitlements; American Red Cross for locator service; military aid societies for family assistance; Office of Personnel Management for pay entitlements and DoD Blanket Routine Uses at: http://dpcld.
defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/. SORN T7347b can be found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570196/t7347b/.
PIA can be found at: https://www.dfas.mil/dam/jcr:4c735dde-6b84-4f24-8153-bd83643c98b1/PIA_DRAS_2010.pdf.
DISCLOSURE: Voluntary; however, if the information is not provided, an appointment of a trustee cannot be made.

INSTRUCTIONS FOR COMPLETING THIS FORM
As a Trustee, you are required to deposit all DoD funds received in a separate bank account, set up under your name as Trustee for the service
member. A report of the administration of the funds received is required by this office. These reports must show dates (month and year), total
amounts, and reasons for payments made. The back of this form may be used for reporting this information. Bank statements must be furnished to
support payments made. Failure to return this form with the required documents, failure to keep proper records of the money spent, or the improper
use of military pay may result in the withholding of future funds and termination of your Trusteeship. Obtain permission from this office for purchases
of$500 or more, other than normal living expenses. Return completed form to the above address.

SECTION I - INFORMATION ABOUT THE SERVICE MEMBER
1. NAME (Last, First, Middle Initial)

2. RANK
(If member is not at home, give name and address of facility)

4. STATUS OF MEMBER (X one)
HOSPITALIZED/
NURSING HOME

3. SOCIAL SECURITY NUMBER

HOME
OTHER (Specify)

SECTION II - SUMMARY OF PAY RECEIVED AND EXPENDED
6. PERIOD COVERED

5. AS OF (YYYYMMDD)

b. TO (YYYYMMDD)

a. FROM (YYYYMMDD)
7. CHECKING ACCOUNT NUMBER(S)

8. SAVINGS ACCOUNT NUMBER(S)

9. NAME AND ADDRESS OF BANK

10. NAME AND ADDRESS OF SAVINGS INSTITUTION

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$

11. BEGINNING BALANCE (Line 16 from previous report)
12. TOTAL MILITARY PAY RECEIVED THIS ACCOUNTING PERIOD

13. TOTAL AMOUNT AVAILABLE THIS ACCOUNTING PERIOD (Add Lines 11 and 12)
14. AMOUNT OF SAVINGS
15. TOTAL AMOUNT PAID DURING THIS ACCOUNTING PERIOD (Totals from Page 2)
16. TOTAL EARNINGS REMAINING AT END OF ACCOUNTING PERIOD (Subtract Line 15 from Line 13):
a. SAVINGS ACCOUNT

$

+ b. CHECKING ACCOUNT

+ c. OTHER INVESTMENTS (Specify in Remarks on back)

$

$

$

SECTION III - AFFIDAVIT
The balance as shown above is deposited in bank or trust company as verified by bank account statements attached. The accounting herein
represents an accurate accounting of all monies received and expended for the benefit of member named for the period shown.
17. TRUSTEE'S NAME (Last, First, Middle Initial)

DD FORM 2826, 20170221 DRAFT

18. RELATIONSHIP TO
MEMBER

19. SIGNATURE

PREVIOUS EDITION IS OBSOLETE.

20. DATE
(YYYYMMDD)

Adobe Designer 11

SECTION IV - TRUSTEE REPORT - ITEMIZATION (Use a separate line for each deposit or withdrawal)
21a. DATE
(YYYYMMDD)

b.
CHECK NO.

c.
PAYER/PAYEE

d.
PURPOSE

e.
DEPOSITS

NEEDS DD 67

22. TOTALS
23. REMARKS

DD FORM 2826 (BACK), 20170221 DRAFT

f.
WITHDRAWALS

g.
BALANCE