Form DD Form 1375 DD Form 1375 Request for Payment of Funeral and/or Interment Expenses

OMB No. 0704-0030
OMB approval expires:

REQUEST FOR PAYMENT OF FUNERAL AND/OR INTERMENT EXPENSES
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The public reporting burden for this collection of information is estimated to average 10 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 IN ITEM 2.

PART I - TO BE COMPLETED BY MILITARY AUTHORITIES
1. MILITARY ACTIVITY PREPARING THIS FORM

2. MILITARY ACTIVITY FORM IS TO BE MAILED TO FOR PAYMENT

a. NAME

a. NAME

b. ADDRESS 6WUHHW&LW\6WDWHDQG=,3&RGH

b. ADDRESS 6WUHHW&LW\6WDWHDQG=,3&RGH

3. NAME OF DECEDENT /DVW)LUVW0LGGOH,QLWLDO

4. PAY GRADE/RANK

5. SERVICE NUMBER/SSN

6. PLACE OF DEATH &LW\6WDWH&RXQWU\

7. DATE OF DEATH<<<<00''

8. NAME OF CLAIMANT /DVW)LUVW0LGGOH,QLWLDO

9. RELATIONSHIP

10. FUNERAL HOME AND/OR NATIONAL CEMETERY
a. NAME

N E E D S

D D

11. GOVERNMENT CONTRACT FOR CARE OF REMAINS IN EFFECT AT PLACE OF DEATH
NO

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b. ADDRESS6WUHHW&LW\6WDWHDQG=,3&RGH

YES (QWHUQDPHRIFRQWUDFWLQJDFWLYLW\

PART II - TO BE COMPLETED BY CLAIMANT3URSHUFRPSOHWLRQZLOOH[SHGLWHVHWWOHPHQW
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G$WWDFKFRSLHVRIELOOVIRUDOODPRXQWVFODLPHG
H0DLOFRPSOHWHGIRUPWRDGGUHVVHHVKRZQLQ,WHP
13. DATE OF
INTERMENT

12. CEMETERY, MAUSOLEUM OR OTHER DISPOSITION
a. NAME

b. ADDRESS 6WUHHW&LW\6WDWHDQG=,3&RGH

<<<<00''

14. INTERMENT COSTS 7REHFRPSOHWHGZKHQFODLPDQWDUUDQJHGIRULQWHUPHQWRQO\
(QWHUWRWDODPRXQWSDLGRULQFXUUHGIRURQHRUPRUHRIWKHIROORZLQJ&RVWRIVLQJOHJUDYHVLWHRSHQLQJDQGFORVLQJ
JUDYHEXULDOYDXOWFKXUFKVHUYLFHRUFOHUJ\
VIHHRELWXDU\QRWLFHIORZHUVVHUYLFHVRIIXQHUDOGLUHFWRULQFOXGLQJXVHRI
IXQHUDOGLUHFWRU
VIDFLOLWLHVDQGPRWRUVHUYLFH
15. FUNERAL ARRANGEMENT COSTS 7REHFRPSOHWHGZKHQFODLPDQWPDGHDOODUUDQJHPHQWV
(QWHUWRWDODPRXQWSDLGRULQFXUUHGIRURQHRUPRUHRIWKHIROORZLQJ&DVNHWSUHVHUYDWLRQHPEDOPLQJDQGUHODWHG
VHUYLFHVFUHPDWLRQDQGXUQFORWKLQJIRUGHFHDVHGFRVWIRULQWHUPHQWVLQJOHJUDYHVLWHRSHQLQJDQGFORVLQJJUDYH
EXULDOYDXOWFKXUFKVHUYLFHRUFOHUJ\
VIHHRELWXDU\QRWLFHIORZHUVVHUYLFHVRIIXQHUDOGLUHFWRULQFOXGLQJXVHRIIXQHUDO
GLUHFWRU
VIDFLOLWLHVDQGPRWRUVHUYLFHDQGVKLSPHQWRIUHPDLQVUHPRYDOIURPSODFHRIGHDWKWRSUHSDUDWLRQSRLQW
GHOLYHU\IURPSUHSDUDWLRQSRLQWWRFRPPRQFDUULHUVKLSSLQJFRVWVUHPRYDOIURPFRPPRQFDUULHUWRUHFHLYLQJIXQHUDO
KRPHDQGGHOLYHU\WRFHPHWHU\
16. SHIPPING COSTS OF REMAINS 7REHFRPSOHWHGZKHQFODLPDQWSDLGRULQFXUUHGFRVWIRUVKLSPHQWRIUHPDLQV
(QWHUWRWDODPRXQWSDLGRULQFXUUHGIRURQHRUPRUHRIWKHIROORZLQJ5HPRYDOIURPSODFHRIGHDWKWRSUHSDUDWLRQ
SRLQWGHOLYHU\IURPSUHSDUDWLRQSRLQWWRFRPPRQFDUULHUVKLSSLQJFRVWVUHPRYDOIURPFRPPRQFDUULHUWRUHFHLYLQJ
IXQHUDOKRPHDQGGHOLYHU\WRFHPHWHU\

AMOUNT CLAIMED


AMOUNT CLAIMED



AMOUNT CLAIMED



17. SHIPMENT OF REMAINS &RPSOHWHZKHQVKLSSLQJFRVWVFODLPHG
a. SHIPPED FROM&LW\DQG6WDWH

b. SHIPPED TO &LW\DQG6WDWH

c. MODE OF SHIPMENT ;RQH
AIR

HEARSE

18. STATEMENT OF CLAIMANT: ,KDYHSDLGRULQFXUUHGH[SHQVHVLQWKHDPRXQWVHQWHUHGLQ,WHPVDQGRU
,GHVLUHWKDWWKHDPRXQWDOORZDEOHE\WKH*RYHUQPHQWEHSDLGWR
a. NAME OF PAYEE3ULQWRUW\SH
c. ADDRESS OF PAYEE 6WUHHW&LW\6WDWHDQG=,3&RGH

DD FORM 1375, 20190507 DRAFT

b. TAXPAYER ID NUMBER OR SSN
d. SIGNATURE OF CLAIMANT

e. DATE SIGNED

PREVIOUS EDITION IS OBSOLETE.

PRIVACY ACT STATEMENT
AUTHORITIES: 10 USC 1481 through 1488, Death Benefits; DoDD 1300.22, Mortuary Affairs Policy; DoDI
1300.18, Department of Defense (DoD) Personnel Casualty Matters, Policies, and Procedures; and E.O. 9397
(SSN), as amended.
PURPOSE: To record amount of funeral and/or interment expenses incurred by next of kin.
ROUTINE USES: Information from these records may be disclosed to the Department of Veterans Affairs, and
other Federal agencies in connection with eligibility, notification and assistance in obtaining benefits due. If
deceased has no spouse, children, representative of minor children, or an executor or personal representative
named in the deceased’s will, then information from these records may be released to the primary next of kin
(PNOK), family member(s) of the injured or deceased DoD personnel to aid in the settlement of the member's
estate. Additional routine uses may be found in the applicable system of records notice, A0600-8-1c AHRC DoD,
Defense Casualty Information Processing System (DCIPS) (https://dpcld.defense.gov/Privacy/SORNsIndex/DODwide-SORN-Article-View/Article/570058/a0600-8-1c-ahrc-dod/).
NOTE: This system of records contains individually identifiable health information. The DoD Health Information
Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of
1996, applies to most such health information. DoD 6025.18-R may place additional procedural requirements on
the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this
system of records notice.
DISCLOSURE: Voluntary; however, if not furnished, claim cannot be paid.

N E E D S

DD FORM 1375 (BACK), 20190507 DRAFT

D D

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