Form DD Form 3116 DD Form 3116 ESCORT REPORT

DCIPS NUMBER

ESCORT REPORT

OMB No. 0704-XXXX
Expires YYYYMMDD

The public reporting burden for this collection of information is estimated to average ## hours/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.
PRIVACY ADVISORY
Disclosure of this information is voluntary and will be used to document a narrative report regarding the shipment of remains and other related matters, including
detailed information of any difficulties that were experienced, within the decedent’s record. When completed, this form contains personally identifiable information
and is protected by the Privacy Act of 1974, as amended.

PART I TO BE COMPLETED BY THE SERVICE MORTUARY AFFAIRS REPRESENTATIVE
1. SERVICE MORTUARY AFFAIRS REPRESENTATIVE NAME
(Last, First, Middle Initial)

2. OFFICIAL MAILING ADDRESS

3. COMMERCIAL PHONE NUMBER 4. NAME OF DECEASED (Last, First, Middle Initial)

5. RANK/GRADE OF THE DECEASED

6. SERVICE (X one)
ARMY

MARINE CORPS

NAVY

AIR FORCE

SPACE FORCE

COAST GUARD

NEEDS DD67

7. NAME OF PERSON AUTHORIZED TO DIRECT DISPOSITION

8. NAME AND ADDRESS OF RECEIVING FUNERAL HOME 9. PHONE NUMBER
(Include Zip Code)

PART II TO BE COMPLETED BY FUNERAL HOME OR REPRESENTATIVE

10. CONDITION OF CASKET AND REMAINS

11. NAME OF RECEIVING INDIVIDUAL

14. SIGNATURE

DD FORM 3116, 20240626 DRAFT

12. FUNERAL DIRECTOR/EMBALMER'S LICENSE # 13. STATE, TERRITORY, OR COUNTRY
(if applicable)

15. DATE (YYYYMMDD)

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PART III TO BE COMPLETED BY ESCORT
16. DATE (YYYYMMDD) AND TIME OF DEPARTURE FOR ESCORT DUTIES 17. DATE (YYYYMMDD) AND TIME OF ARRIVAL AT DESTINATION

18. CONDITION OF CASKET (X one)
NOT DAMAGED - ACCEPTABLE

DAMAGED

IF DAMAGED, DESCRIPTION OF DAMAGE AND ACTION TAKEN TO RESOLVE:

19. REMARKS (Include issues and concerns)

NEEDS DD67

20. NAME AND GRADE OF ESCORT

21. SIGNATURE

22. DATE (YYYYMMDD)

23. REVIEWED BY SERVICE MORTUARY AFFAIRS REPRESENTATIVE
(Name and Grade)

24. SIGNATURE

25. DATE (YYYYMMDD)

DD FORM 3116, 20240626 DRAFT

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