DD-2761 Personal Check Cashing Agreement

OMB No. 0730-0005
OMB approval expires
XXXXXXXX

PERSONAL CHECK CASHING AGREEMENT

The public reporting burden for this collection of information is estimated to average 15 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]. 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
WHICH PROVIDED THIS FORM.
PRIVACY ACT STATEMENT
AUTHORITY: 31 U.S.C. Section 3342, E.O. 9397, and DoD Financial Management Regulation (DoDFMR) 7000.14-R, Volume 5, Chapter 4.
PRINCIPAL PURPOSES: This form is designed exclusively to help overseas and afloat DoD disbursing activities, expedite the collection
process of dishonored checks overseas and afloat.
ROUTINE USES: The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act of
1974, as amended. It may also be disclosed outside of the Department of Defense to Federal, state, or local government agencies, which have
identified a need to know, for the purpose(s) identified in the DoD Blanket Routine Uses as published in the Federal Register.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in refusal to cash personal checks.

PLEASE PRINT OR TYPE ALL INFORMATION.
1. NAME (Last, First, Middle)

2. SOCIAL SECURITY NUMBER

3. ORGANIZATION/LOCATION

4. RANK/GRADE
5. DUTY TELEPHONE NUMBER
(Include Area Code)

6. BRANCH OF SERVICE

NEEDS DD67
7. SUPERVISOR'S NAME (Last, First, Middle Initial)

8. SUPERVISOR'S TELEPHONE NUMBER
(Include Area Code)

9. HOME ADDRESS (Street, Apartment Number, City, State, ZIP Code)

10. HOME TELEPHONE NUMBER
(Include Area Code)

11. DRIVER'S LICENSE NUMBER

12. DRIVER'S LICENSE STATE

POWER OF ATTORNEY
I desire to execute a power of attorney and I appoint and by these presents do make, constitute and appoint the below listed
individual(s) my true and lawful attorney(s)-in-fact to draw, make, endorse, and cash personal checks drawn upon any account
which I may have as sole or joint owner. Any act performed hereunder for me or from my account shall be binding on me, my
heirs, legal and personal representatives and assigns. Transactions under this authority shall be in my name and all
endorsements and instruments executed by my attorney shall contain my name, followed by that of my attorney and the
designation "Attorney-in-Fact".
13. AUTHORIZED AGENT

14. AUTHORIZED AGENT

15. AUTHORIZED AGENT

16. AUTHORIZED AGENT

"In consideration of the extension of the privilege to have personal checks cashed by a Department of Defense finance/
disbursing officer, I hereby freely and voluntarily consent to the immediate collection from my current pay, without prior notice or
prior opportunity to be heard, the face value of any check cashed by myself or my authorized agents, plus any charges
assessed against the government by a financial institution, in the event such instrument is dishonored and returned for
insufficient funds or closed accounts."
17. REQUESTOR'S SIGNATURE

DD FORM 2761, DRAFT 20210415

18. DATE

PREVIOUS EDITION IS OBSOLETE.

Reset

LOCAL REPRODUCTION AUTHORIZED.
Adobe Professional 7.0

NOTE: If individual has been transferred, forward this
authorization to the officer currently maintaining
the individual's pay record.

PAY ADJUSTMENT AUTHORIZATION
1. MEMBER/EMPLOYEE NAME (Last, First, Middle)

2. SSN

3. RANK/GRADE

5. PAY GRADE NUMBER

6. AMOUNT

7. APPROPRIATION DATA

8. FROM

4. BRANCH OF SERVICE

9. NAME OF ACCOUNTABLE DISBURSING OFFICER
(D.O.)
10. D.O. SYMBOL

12. TO

11. G.A.O. EXCEPTION
CODE

13. YOU ARE HEREBY AUTHORIZED TO DEDUCT
THE AMOUNT OF $ _______________________
FROM THE ACCOUNT OF THE ABOVE NAMED
INDIVIDUAL.

14. EXPLANATION AND/OR REASON FOR ADJUSTMENT

NEEDS DD67
I CERTIFY that this collection is the result of dishonored personal checks cashed by the cited individual for the amounts
stated. The individual has consented in writing, that in consideration for cashing the individual's check(s) the amount of any
check returned unpaid for any reason, plus any charges assessed against the government by a financial institution, may be
collected from the individual's pay.
15. FROM

16. DISBURSING OFFICER
a. NAME (Last, First, Middle Initial)

b. RANK/GRADE c. SIGNATURE

I CERTIFY that the adjustment indicated above has been entered on the above-named individual's Pay Record.
(If adjustment has not been entered, give explanation in the space provided above.)
17. TO

18. PAYROLL OFFICER
a. NAME (Last, First, Middle Initial) (Type or Print)

19. PAYROLL DSSN

b. RANK/GRADE

20. DATE

21. SIGNATURE

DD FORM 2761 (BACK), DRAFT 20210415

Reset