Dd2789 Waiver/remission Of Indebtedness Application

WAIVER/REMISSION OF INDEBTEDNESS APPLICATION

If more space is needed, continue on separate sheet(s). Identify each item by number. For further guidance with completing this form,
please visit: www.dfas.mil/waiversandremissions.html

OMB No. 0730-0009
OMB approval expires

The public reporting burden for this collection of information is estimated to average 2 hours 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 the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at [email protected] (0730-0009). 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.
-

Active duty military, Guard/Reserve, retired or annuitant pay recipients, civilian employees, return completed form to the address listed on WKHGHEWnotification letter for completion of
the back side.
Separated Military or former civilian employees, please see instructions website regarding where to send your claim.
Current Active Duty Military, Guard, Reserve, Retired or Annuitant Pay Recipients, Civilian Employees: Complete Fields 1-19 For completion of the second page of the form. RETURN
THE FORM TO: DFAS-IN DEPT 3300 (WAIVER/REMISSION), 8899 East 56TH Street, Indianapolis, IN 46249-3300 Unless instructed to send to a different address on debt notification letter.
Separated Military or Former Civilian Employees complete fields 1-19. Send form to DFAS-IN DEPT. 3300 (WAIVER/REMISSION), 8899 East 56TH Street, Indianapolis, IN 46249-3300

Read Privacy Act Statement and Instructions beginning on Page 3 before completing form

1. TYPE OF CLAIM ;RQH

WAIVER

REMISSION (Not applicable for civilians) (If Army, please use DA Forms 3508 and 2823.) Authority for
granting waiver: Active/Retired Military - 10 U.S.C. 2774; National Guard - 32 U.S.C. 716; Civilian - 5 U.S.C. 5584; Annuitant - 10 U.S.C. 1442/1453. Remission: Army - 10
U.S.C. 4837; Navy - 10 U.S.C. 6161; Air Force - 10 U.S.C. 9837.
SECTION I - CIVILIAN/MILITARY/RETIREE/ANNUITANT INFORMATION
2. NAME (Last, First, Middle Initial)
5. AGENCY/SERVICE
OTHER (Specify)

ARMY

4. SOCIAL SECURITY NUMBER

3. RANK/GRADE

6. STATUS (X applicable block and provide date (YYYYMMDD) for end of enlistment period (EOE),
retirement (DOR), separation (DOS), or service computation date (SCD), as appropriate.)

NAVY

ACTIVE

EOE:

SEPARATED

AIR FORCE

GUARD/RESERVE

EOE:

DOD CIVILIAN SCD:

MARINE CORPS

RETIRED

DOR:

ANNUITANT

8. PLACE OF ASSIGNMENT OR
EMPLOYMENT

9. TELEPHONE (Include DSN or area code)

7. CURRENT COMPLETE MAILING ADDRESS (Street, City, State,
ZIP Code)

DOS:

a. WORK
b. HOME
c. E-MAIL ADDRESS:

10. TYPE OF DEBT OR ERRONEOUS PAYMENT

11. GROSS DEBT AMOUNT

12. STATE THE DATE AND HOW YOU FIRST BECAME AWARE OF DEBT OR ERRONEOUS PAYMENT. (Attach notification, if available.)

13. IF YOU WERE AWARE OF DEBT OR ERRONEOUS PAYMENT, EXPLAIN THE ACTIONS YOU TOOK TO CORRECT SITUATION.

N E E D S

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14. REASON FOR REQUESTING WAIVER/REMISSION AND WHY YOU BELIEVE IT SHOULD BE APPROVED (Financial hardship applies ONLY
to REMISSION and if claimed, a financial statement must be attached to include all supporting documentation.)

15. FOR ANNUITANTS, PROVIDE NAME, SSN AND DATE DECEASED OF MILITARY MEMBER/SPONSOR.
16.a. ATTACH COPIES OF ALL PERTINENT DOCUMENTS (Such as Request for BAH, Statement of Service, Separation Worksheet, DD Form 214,
Travel Voucher, Notification of Personnel Action). (If not available, please explain.)

c. HR POC PHONE:

b. HR POINT OF CONTACT (Civilian employees):

17.a. IF MILITARY OR CIVILIAN, DID YOU RECEIVE LEAVE AND EARNINGS STATEMENT(S)?
b. IF MILITARY OR CIVILIAN, DID YOU REQUEST THEM ON MYPAY?
c. IF RETIREE OR ANNUITANT, DID YOU RECEIVE AN ACCOUNT STATEMENT?
d. IF RETIREE OR ANNUITANT, DID YOU REVIEW THEM?

YES

NO

YES
YES

NO
NO

YES

NO

(If answer to a. or c. is Yes, attach a copy of statement covering before, during, and after period. If No, explain why.)
YES
NO
18. HAVE YOU FILED FOR A CORRECTION OF MILITARY RECORDS?
19. I certify the above statements are true and correct to the best of my knowledge. The information presented may be referred to the
appropriate investigating office for verification. I understand the penalty for a false claim is a maximum fine of $10,000 or a maximum
imprisonment of 5 years, or both.
a. SIGNATURE (Electronic/Typed not accepted)

b. JOB TITLE/CAREER FIELD

DD FORM 2789, 20180205 DRAFT

PREVIOUS EDITION IS OBSOLETE.

c. DATE SIGNED

Page 1 of 6 Pages
Adobe Professional X

20. COMMANDER'S OR SUPERVISOR'S ENDORSEMENT (Required for active duty, reserves, guard, and Federal civilian employees. Use separate sheet of
paper LIQHHGHG

21. RECOMMENDATION:
APPROVE
22.a. COMMANDER'S OR SUPERVISOR'S NAME
(Please print)

$

PARTIAL

DENY

RECOMMEND COLLECTION RATE

$

c. DATE SIGNED

b. SIGNATURE (Electronic/Typed not accepted)

SECTION II - REPORT OF INVESTIGATION
To be completed and signed by appropriate payroll/travel office. (Not applicable for retirees, annuitants, or out-of-service military members.)
23. INFORMATION ON DEBT OR ERRONEOUS PAYMENT(S)
a. GROSS DEBT AMOUNT

b. TYPE(S) OF PAYMENT(S)

c. DATE(S) OF PAYMENT(S)
YES NO

d. (X and complete as applicable)

(5) DATE THE DEBT WAS DISCOVERED

(1) HAS THE DEBT BEEN VALIDATED?
(6) NAVY ONLY: AMOUNT UNCOLLECTED AS OF
DATE OF THE COMMANDER'S SIGNATURE:

(2) HAS THE DEBT BEEN POSTED TO THE DEBTOR'S RECORDS?
(3) REMISSION: HAS THE COLLECTION ACTION BEEN SUSPENDED?

$

(4) WAIVER: HAS FINANCE OFFICE SUSPENDED COLLECTION IAW DODFMR, VOL. 5, CH. 31?

24. A DEBT COMPUTATION MUST ACCOMPANY THIS APPLICATION. It must include dates of erroneous payments, what was paid (broken down
by month by entitlements), what should have been paid, and the difference. The total debt must equal the debt posted to the debtor's record.
Indicate any entitlements or credits used to offset the debt. This application will be returned without action if the computation is not
included. See instructions website for examples.
a. ENTITLEMENT

b. DATE(S)

c. WAS PAID

d. SHOULD HAVE BEEN PAID

e. DIFFERENCE

25. DETAILED STATEMENT OF HOW AND WHY ERROR OCCURRED.

N E E D S

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26. IS THERE ANY INDICATION OF FRAUD, MISREPRESENTATION, FAULT, OR LACK OF GOOD FAITH ON THE PART OF THE CLAIMANT?
NO
YES (Explain)
27. STATEMENT AS TO WHETHER OR NOT THE CLAIMANT KNEW OR SHOULD HAVE BEEN AWARE OF RECEIVING AN ERRONEOUS
PAYMENT. (Furnish facts and circumstances to support answer, state whether claimant received documents, and provide copies, if
available. Use a separate sheet of paper if additional space is required.)

28. REMARKS (Attach a separate sheet of paper, if needed.)

29. RECOMMENDATION:

APPROVE

PARTIAL

$

DENY

30. DESIGNATED FINANCIAL AGENT
a. SIGNATURE (Electronic/Typed not accepted)

31a. COMPLETE UNIT MAILING ADDRESS

b. TITLE

c. DATE SIGNED

b. POINT OF CONTACT NAME
c. TELEPHONE

e. ADSN/DSSN/UIC

DD FORM 2789, 20180205 DRAFT

d. DSN

f. E-MAIL ADDRESS

Page 2 of 6 Pages

PRIVACY ACT STATEMENT
AUTHORITY: Waiver authority: 10 U.S.C. 1442, "Recovery of Annuity Erroneously Paid;" 10 U.S.C. 1453, "Recovery of Amounts
Erroneously Paid;" 10 U.S.C. 2774, "Claims for Overpayment of Pay and Allowances and of Travel and Transportation Allowances;"
32 U.S.C. 716, "Claims for Overpayment of Pay and Allowances, and Travel and Transportation; and E.O. 9397 (SSN), as amended.
Remissions authority: Navy 10 U.S.C. 6161; Air Force 10 U.S.C. 9837
PRINCIPAL PURPOSES(S): To be used by civilian employees (current, former, or retired) and military members (active, separated or
retired), and annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances and
expense reimbursement or allowances for travel, transportation, and relocation; or in the case of enlisted members, remission of debts.
ROUTINE USE(S): For a complete list of routine uses, visit the applicable systems of records notices:
T7332, Defense Debt Management System: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/
Article/570181/t7332/
T7335, Defense Civilian Pay System: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570184/
t7335/
T7340, Defense Joint Military Pay System – Active Component: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORNArticle-View/
Article/570191/t7340/
T7344, Defense Joint Military Pay System – Reserve Component: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORNArticle-View/
Article/570195/t7344/
DISCLOSURE: Voluntary; however, failure to provide this information will result in initiating administrative or salary offset
procedures under the provision of the Debt Collection Act of 1982 (Pub. L. 97-365, as amended by Pub L. 104-134, the Debt Collection
Improvement Act of 1996).
INSTRUCTIONS FOR COMPLETING DD FORM 2789,
WAIVER/REMISSION OF INDEBTEDNESS APPLICATION
Please note: If you do not agree with the validity of your debt, a waiver request cannot be processed. You must first agree that the debt
is valid. This is not admission to or agreement that you should be responsible for the repayment of the debt. It merely means that you
agree that you received an erroneous payment or an overpayment. Once you agree with the validity of the debt you may file for waiver at
that time. Please visit www.dfas.mil/waiversandremissions for guidance with completing and submitting your waiver.
To complete the DD Form 2789, please follow instructions below. Please note that an incomplete DD Form 2789 will delay the
processing of the Remission/Waiver consideration. Carefully read and complete all information as requested, and be sure to
include any required documentation with your submission. If DFAS does not receive a valid DD Form 2789, the indebtedness
will continue to be collected. For sections 10 through 16, if you need additional space for this information you can attach a typed
and a signed document. All fields must be filled out. If some fields do not apply to you, please put Not Applicable (N/A).

INSTRUCTIONS BY SECTION:

N E E D S
Section

1.

Type of claim (Remission/Waiver)
(Required)

D D

Instructions

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Place an “X in appropriate box. All service members may apply for

Remission. (Army, Navy, AF, and USM C). Waiver applicants please
refer to http://www.dfas.mil/waiversandremissions.html
for the Remission process.
USMC-please refer to
http://www.dfas.mil/waiversandremissions.html
to reference address. The debt had to occur while on Active Duty,
not National Guard Bureau, or Reserve Duty.
AF/USMC-use DD Form 2789. Please refer to
http://www.dtic.mil/whs/directives/infomgt/forms/eforms/dd2789.pdf
and send the DD Form 2789 to your agency.
Army - use DA Form 3508. Please refer to http://
armypubs.army.mil/eforms/pdf/a3508.pdf

DD FORM 2789, 20180205 DRAFT

and send the DA Form 3508 to the Army (HRC).
Page 3 of 6 Pages

INSTRUCTIONS: Page 1, Section I - Civilian/Military/Retiree/Annuitant Information
2.

Name (Required)

3.

Rank/Grade (status at the time of debt)
(Required)

Civilians: Grade.
Military: Rank.
Retirees: Retired rank/rate.
Annuitants: Not applicable.

4.

Social Security Number (Required)

Debtor’s Social Security Number.

5.

Agency/Service (Required)

Civilian: Check “Other” and specify what Agency at the time
of debt.
Military: Mark branch of Service.
Retirees: Mark branch of Service.
Annuitants: Mark “Other” and specify “Annuitant”.

6.

Status at the time of debt (Required)
Please “X” the applicable box and provide date
(YYYYMMDD) for end of enlistment period (EOE),
retirement (DOR), or service computation date (SCD),
as appropriate.

Active: Fill in “EOE”.
Guard/Reserve: Fill in “EOE.
Retired: Fill in “DOR”.
Separated: Fill in “DOS”.
DOD Civilian: Fill in “SCD”.
Annuitant: Only need to “X” the box, no date needed.

7.

Current mailing address (Required)

Current mailing address

8.

Place of assignment or Employment

Civilian: Employing Agency.
Military: Employing Agency/Assignment.
Retirees: Not applicable (Mark N/A).
Annuitants: Not applicable (Mark N/A).

9a.

Work Telephone (Required)

Work telephone number (if applicable).

9b.

Home Telephone (Required if no work phone)

Home and/or cell telephone number.

9c.

E-Mail Address

.gov or .mil e-mail preferred.

10

Type of Debt or Pay and Allowance Erroneously Paid

Brief description of debt as stated in debt notification letter.

11.

Gross Debt Amount (Required)

Gross debt amount provided on debt notification letter.

12.

State the date and how you first became aware of
the erroneous payment.
(Required)

Date debt notification letter (or other correspondence, if
applicable) was received. Attach copy of notification letter
or other correspondence.

13.

If you were aware of the debt or erroneous payment,
explain the actions you took to correct the situation.
(Required)

Explain any actions taken to correct the debt or prevent debt
from occurring. If needed, explanation can continue on
additional pages. Any additional explanations and
documentation (emails, letters, etc.) showing your attempts
should be signed and submitted with the completed form.

14.

Reason for requesting a Remission/Waiver and
why you feel it should be approved.
(Required)

Explain why you think your Remission/Waiver request should
be approved. Submit any additional documentation with
the completed form.

15.

For Annuitants, provide name, SSN, and date of
death of deceased Military member/sponsor.
(Required)

Retirees: Not Applicable (Mark N/A).
Annuitants: State deceased spouse/sponsor’s full name, SSN,
and date of death.

N E E D S

DD FORM 2789, 20180205 DRAFT

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Page 4 of 6 Pages

INSTRUCTIONS: Page 1, Section I - Civilian/Military/Retiree/Annuitant Information (Continued)
16a.

Attach copies of all pertinent documents
(Required)

Attach any supporting documentation from parts #12
through #14.

16b.

HR Point Of Contact (POC) (Civilian employees
only) (Required)

Write HR contact and Telephone number.

16c.

HR POC phone

17a.

If Military or Civilian, did you receive Leave
and Earnings Statement(s)? (Required)

Retirees and Annuitants: Not Applicable.

17b.

If Military or Civilian, did you request them on
on My Pay? (Required)

Retirees and Annuitants: Not Applicable.

17c.

If Retiree or Annuitant, did you receive a
Retiree Account Statement?
(Required)

17d.

If Retiree or Annuitant, did you review them?
(Required)

18.

Have you filed for a Correction of Military
Records? (Required)

Military and Retirees: Mark “Yes” if you have filed for a
Correction to Military Record. (Please provide all
documentation from the Board of Corrections concerning their
findings). Mark “No” if you have not filed for a Correction to
Military Record. Annuitants can request a change through
Annuity Pay Office.

19a

Signature (Handwritten)
(Required)

Sign form if you certify that your statements on this form are
true and correct to the best of your knowledge. An unsigned
form is considered invalid, cannot be processed, and will be
returned.

19b.

Job Title/Career Field

Civilian and Military: Career Field Retirees: Mark “Retired”
Annuitants: Mark “Annuitant”.

19c.

Date signed (Required)

Mark date form was completed and signed. An undated form is
considered invalid, cannot be processed, and will be returned.

N E E D S

Retirees and Annuitants: Mark “Yes” if you received an
Account Statement regarding the debt. Mark "No" if you did
not receive an Account Statement regarding the debt.
If “Yes”, attach a copy of the statement covering before,
during, and after notification.
Retirees and Annuitants: Mark “Yes” if you reviewed the
Account Statement. .Mark “No’ if you did not review the
Account Statement.

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Page 2: Parts 20 through 31. Section I - Active duty/Reserves/Federal Civilian Employees
20.

Commander’s or Supervisor’s
Endorsement

21.

Recommendation

22a.

Commander’s or Supervisor’s Name

22b.

Commander’s or Supervisor’s
Handwritten Signature

22c.

Date Signed

Please have your commanding officer or supervisor provide a
statement giving his or her opinion on the Waiver/Remission
request. Required for Navy active duty and reserves guard.
Recommended for Federal civilian employees, active duty
Army, Air Force, and USMC.

Section II - Report of Investigation. To be completed and signed by Military payroll/travel office/civilian payroll, or finance
office. (not applicable for retirees, annuitants, or out of service military members).
23a.

Gross Debt Amount

Amount of Gross Debt.

23b.

Type(s) of Payments

List type of payments included in debt.

DD FORM 2789, 20180205 DRAFT

Page 5 of 6 Pages

INSTRUCTIONS: Page 2, Section II - Report of Investigation (Continued)
23c.

Date(s) of Payment(s)

List the dates of payments received.

23d1.

Has the debt been validated?

Check yes or no.

23d2.

Has the debt been posted to the debtor’s records?

Check yes or no.

23d3.

Remission: Has the collection action been suspended? Check yes or no.

23d4.

Waiver: Has finance office suspended collection
in accordance with DODFMR Vol 5, Ch-31?

Check yes or no.

24a.

Entitlement

Provide type(s) of entitlement included in debt
broken down monthly.

24b.

Dates

Provide exact dates of the indebtedness. The debt
must be broken down by month.

24c.

Was Paid

Provide the amount member was paid, broken down
by month.

24d.

Should have been paid

Provide the amount the member should have been paid,
broken down by month.

24e.

Difference

Provide the difference amount between what the member was
paid, and should have been paid. The difference amount must
be broken down by month.

25.

Detailed statement of how and why error occurred.

Provide detailed explanation for how and why the error occurred.

26.

Is there any indication of fraud, misrepresentation,
fault, or lack of good faith on the part of the
claimant?

Check yes or no, if yes, please provide a detailed explanation.

27.

Statement as to whether or not the claimant knew
or should have been aware of receiving an erroneous
payment.

Provide a detailed statement which indicates whether the
claimant knew or should have known he or she was receiving
erroneous payments.

28.

Remarks

Provide any additional statements, facts, or remarks.

29.

Recommendation

Provide recommendation for waiver request.
Please indicate approve, partial, or deny.

N E E D S

.

D D

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30a.

Designated Financial Agent Handwritten Signature

Provide hand written signature of designated financial agent.

30b.

Title

Provide title of signature of designated financial agent.

30c.

Date Signed

Provide date of signature of designated financial agent.

31a.

Complete Unit mailing Address

Provide complete mailing address of Unit.

31b.

Point of Contact Name

Provide point of contact for questions regarding the
Waiver/Remission request.

31c.

Telephone

Provide telephone number for the point of contact.

31d.

DSN

Provide DSN for point of contact.

31e.

ADSN/DSSN/UIC

Provide applicable ADSN, DSSN, UIC.

31f.

E-Mail Address

Provide e-mail address for point of contact.

DD FORM 2789, 20180205 DRAFT

Page 6 of 6 Pages