Form DD Form 2653 DD Form 2653 Involuntary Allotment Application

OMB No. 0704-0367
OMB approval expires
XX/XX/XXXX

INVOLUNTARY ALLOTMENT APPLICATION

The public reporting burden for this collection of information, 0704-0367, is estimated to average 30 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. SEND YOUR COMPLETED FORM TO THE ADDRESS IN THE
INSTRUCTIONS BELOW.

Privacy Act Statement - DD Form 2653
AUTHORITIES: AUTHORITIES: 5 USC 5520a(k) (also known as “Government Organization and Employees”); 42 USC 651-665 (also known as “The Public
Health and Welfare Act”); 15 USC 1601 note, 1601-1614, 1631-1646, 1661-1665a, 1666-1666j, 1667-1667e (also known as “Truth in Lending Act”); 10 USC
801-940, 15 USC 1601 note, 1692-1692o (also known as “Uniform Code of Military Justice, Articles 1-140”); 15 USC 1692 (also known as "Fair Debt Collection
Practices Act"); 50 USC 501-591 (also known as “The Servicemembers Civil Relief Act”, as amended); DoD Directive (DoDD) 1344.9, ”Indebtedness of Military
Personnel,” Dec. 8, 2008; DoDD 7000.14-R, “DoD Financial Management Regulation,” Volume 7A, Chapter 50, Sept. 2006; DoDD 5500.7, “Standards of
Conduct,” Aug. 30, 1993; DoDD 5124.02, “Under Secretary of Defense for Personnel and Readiness (USD(P&R)),” Jun. 23, 2008.
PRINCIPAL PURPOSES: Used by the Department of Defense to initiate an involuntary allotment from the pay of a member of the Uniformed Service for
indebtedness owed a third party as determined by the final judgment of a court. The form requires the creditor to provide identifying information on the member
of Uniformed Services; certify a judgment was obtained and that the members rights under the Servicemembers Civil Relief Act were protected. For additional
information, see the system of records notices for Defense Financial Accounting Services (DFAS) T7340, T7344, T7347b, T5500b and M01040-3 (Marine Corps
Total Force System (MCTFS)) published at http://www.defenselink.mil/privacy/notices/dfas.
ROUTINE USES: This form is subject to the proper and necessary routine uses identified in the system of records notice(s) specified in the purpose statement
above. Information provided will further be disclosed to the DFAS to initiate the involuntary allotment from the member of the Uniformed Service for indebtedness.
DISCLOSURE: Voluntary. However, failure to provide all requested information may result in not processing this form.

NEEDS DD67
INSTRUCTIONS

1. These instructions govern an application for involuntary allotment payment from Military Service (or Coast Guard) member's active or
reserve/guards pay under 5 USC Section 5520a.
2. In order to be processed, this form must be filled out completely, signed, and the following supporting documents attached:
a. A copy of the judgment, certified by the clerk of the appropriate court;
b. If the applicant is other than the original judgment holder, proof of the applicant's right to succeed to the interest of the original
judgment holder.
3. Submit the original and two copies of this application and all supporting documents to:
For Army, Navy, Air Force and Marine Corps:
Defense Finance and Accounting Service
Cleveland Center, Code GAG
PO Box 998002
Cleveland, OH 44199-8002
http://www.dfas.mil/money/garnish/

For Coast Guard:
Commanding Officer
U.S. Coast Guard
Personnel Service Center (LGL)
444 S.E. Quincy Street
Topeka, KS 66683-3591

SECTION 1 - IDENTIFICATION
1. APPLICANT
I hereby request that an involuntary allotment be established from the pay of the following identified member of the Military Services/ Coast Guard pursuant to
the provisions of Pub. L. No. 103-94, the Hatch Act Reform Amendments of 1993. The debt in question has been reduced to a judgment. A copy of the
judgment, as certified by the appropriate Clerk of Court, is attached.
a. APPLICANT NAME (Provide whole name whether person or business)

b. TELEPHONE NUMBER (Include area code)

c. ADDRESS
(1) STREET AND APARTMENT OR SUITE NUMBER

(2) CITY

(3) STATE

(4) ZIP CODE (9 Digit)

Alabama
2. SERVICE MEMBER

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b. SSN

a. NAME (Last, First, Middle Initial)

c. BRANCH OF SERVICE

d. CURRENT DUTY ASSIGNMENT (If known)

e. CURRENT ADDRESS (If known)
(1) STREET AND APARTMENT OR SUITE NUMBER

(2) CITY

(3) STATE

(4) ZIP CODE (9 Digit)

Alabama
3. CASE
a. CASE NUMBER (As assigned by court) b. NAME OF ORIGINAL JUDGEMENT HOLDER (If different from applicant) c. ACCOUNT NUMBER OF DEBTOR

d. JUDGMENT AMOUNT
(1) DOLLAR AMOUNT OF JUDGEMENT

(2) DOLLAR AMOUNT OF INTEREST OWED TO DATE OF
APPLICATION

(3) TOTAL DOLLAR AMOUNT DUE
(Total of sub-blocks (1) and (2))

SECTION II - APPLICANT CERTIFICATION
4. I HEREBY CERTIFY THAT:
a. (X as applicable)
(1) The judgment has not been amended, superseded, set aside, or satisfied;
(2) If the judgment has been paid in part, the total remaining to be paid is
b. (X as applicable)

$

NEEDS DD67

(1) The judgment was issued while the member was not on active duty; or

(2) If the judgment was issued while the member was on active duty, that member was present or represented by an attorney of the member's choosing in
the proceeding's; or
(3) If the member was not present or represented by an attorney at the judicial proceedings, that the judgment complies with the Service members Civil
Relief Act, 50 U.S.C. App. Sections 501-596 (2003). (If you obtained a default judgment and it does not contain language that indicates that the plaintiff
complied with 50 U.S.C. App. 501-593, then you must submit proof that an affidavit stating the member's military service status, as required by 50 U.S.C.
App. 520, was filed with the court prior to entry of the judgment.)
c. The member's pay could be garnished under applicable State law and 5 USC 5520a if the member were a civilian employee;
d. To the best of my knowledge, the debt has not been discharged in bankruptcy nor has the member filed for protection from creditors under the
bankruptcy laws of the United States;
e. I will promptly notify you to discontinue the involuntary allotment at any time the judgment is satisfied prior to the collection of the total amount of the
judgment through the involuntary allotment process;
f. If the member overpays the amount owed on the judgment, I will refund the amount of overpayment to the member within 30 days of discovery or notice
of the overpayment, whichever is earlier, and that if I fail to repay the member, I understand that I may be denied the right to collect by involuntary allotment
on other debts reduced to judgments.
5. I HEREBY ACKNOWLEDGE THAT:
As a condition of application, I agree that neither the United States, nor any disbursing official or Federal employee whose duties include processing
involuntary allotment applications and payments, shall be liable with respect to any payment or failure to make payment from moneys due or payable by the
United States to any person pursuant to this application.
6. CERTIFICATION
I make the foregoing statement as part of my application with full knowledge of the penalties involved for willfully making a false statement (U.S. Code, Title
18, Section 1001, provides a penalty as follows: Shall be fined under this title or imprisoned not more than 5 years, or both.
a. TYPED NAME (Last, First, Middle Initial)

b. TELEPHONE NO. (Include area code)

c. SIGNATURE

d. DATE SIGNED (YYYYMMDD)

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