Form DD Form 3005 DD Form 3005 Application for Surrogate Association for DoD Self-Servi

CUI (when filled in)
OMB No. 0704-0559
OMB approval expires:
20241130

APPLICATION FOR SURROGATE ASSOCIATION FOR DOD SELF-SERVICE (DS) LOGON

The public reporting burden for this collection of information is estimated to average 6 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 ADDRESS. RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL
IDENTIFICATION SYSTEM WORK STATION.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Manual 1341.02, Volume 1, DoD Identity Management: DoD SelfService (DS) Logon Program and Credential and E.O. 9397 (SSN), as amended.
PURPOSE(S): To establish a Defense Enrollment Eligibility Reporting System (DEERS) record and surrogate association for issuance of a DoD Self-Service
(DS) Logon. A surrogate may be established: (1) As the custodian of an unmarried minor child(ren) of a Service member who is under age 18, who is at least 18
but under 23 and attending school full-time, or who is incapacitated. (2) As the agent of an incapacitated dependent (e.g., spouse, parent). (3) As the agent of a
wounded, ill, or mentally incompetent Service member.
ROUTINE USE(S): To the Social Security Administration, for the purpose of verifying the surrogate's identity. For a complete list of routine uses, visit the
applicable system of records notice at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-dod/
DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a DS Logon.

SECTION I - SURROGATE INFORMATION
1. SURROGATE FULL NAME (Last, First, Middle)

2. GENDER (Select)

3. DATE OF BIRTH (YYYYMMDD)

4. SSN or DoD ID NUMBER

5. HOME ADDRESS
b. CITY

a. STREET ADDRESS (Include Apartment Number)

c. STATE

6. PRIMARY EMAIL ADDRESS

d. ZIP CODE

e. COUNTRY

7. TELEPHONE NUMBER (Include Area Code)

SECTION II - BENEFICIARY INFORMATION
9. BENEFICIARY SSN or DoD ID NUMBER

8. BENEFICIARY FULL NAME (Last, First, Middle)

10.a. SPONSOR SSN or DoD ID NUMBER (If Beneficiary is not the Sponsor)

10.b. SPONSOR SSN or DoD ID NUMBER (If Beneficiary has two Sponsors)

11. SURROGATE ASSOCIATION ON BEHALF OF A BENEFICIARY (X one or more, as appropriate)
Agent. A person named by the beneficiary to assist the beneficiary with specific matters as designated. If the beneficiary is a dependent, the dependent
must be over age 18, eligible for DoD benefits in accordance with DoD Manual 1000.13, Volume 2, and competent to consent to contract. If the
beneficiary is a minor dependent, the person authorized to act on the beneficiary’s behalf must name the agent. Surrogacy access permissions may be
restricted in accordance with applicable State, Federal and HIPPA laws and regulations.
Financial Agent (FA). Assists the beneficiary with financial matters.
Legal Agent (LA). Assists the beneficiary with legal matters.
Caregiver (CG). Assists the beneficiary with general health care requirements (example, viewing general health care-related
information, scheduling appointments, refilling prescriptions, and tracking medical expenses) but does not make health care
decisions.
Health Care Agent (HA). Named by the beneficiary (the patient) in a Durable Power of Attorney for Health Care document
executed before the beneficiary loses decision-making ability.
Legal Guardian (LG). Appointed by a court of competent jurisdiction in the United States (or jurisdiction of the United States) to make decisions for the
beneficiary to include Custodians and ex-spouse parents supported by documentation that includes but is not limited to legal custody court orders and
divorce decrees granting the ex-spouse custody of the beneficiary.
Special Guardian (SG). Appointed by a court of competent jurisdiction in the United States (or jurisdiction of the United States) for
the specific purpose of making health care-related decisions for the beneficiary.

DD FORM 3005, APR 2019
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Controlled by: DoDHRA DMDC Identity and ID Card Policy
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: [email protected]

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12. START DATE OF SURROGACY (YYYYMMDD)

13. END DATE OF SURROGACY (YYYYMMDD)

14. SURROGATE SIGNATURE

15. DATE SIGNED

16. BENEFICIARY SIGNATURE (Or person authorized to sign on behalf of the Beneficiary)

17. DATE SIGNED

SECTION III - CERTIFYING OFFICIAL INFORMATION
To be completed by a SJA, local JAG, or attorney, or by the Service Project Office. Required if establishing a Surrogate association on behalf of (1) a minor child
(under age 18); (2) an incapacitated beneficiary; (3) a beneficiary to establish a Health Care Agent Surrogate association (must be accompanied by Durable
Power of Attorney for Health Care); or (4) a beneficiary to establish a Legal Guardian or a Special Guardian Surrogate association (must be accompanied by
court document).
18. CERTIFYING OFFICIAL FULL NAME (Last, First, Middle)

19. CERTIFYING OFFICIAL TELEPHONE NUMBER (Include Area Code)

20. CERTIFYING OFFICIAL EMAIL ADDRESS

21. CERTIFYING OFFICIAL ADDRESS (Include ZIP Code)

22. CERTIFICATION (X as applicable)

This is to certify that a Durable Power of Attorney for Health Care has been reviewed and authorizes establishment of a Health
Care Surrogate association. The Durable Power of Attorney for Health Care document is attached.
This is to certify that a court document from a court of competent jurisdiction in the United States (or possession of the United
States) has been reviewed and authorizes establishment of a Legal Guardian or a Special Guardian Surrogate association.
The court document is attached.
23. CERTIFYING OFFICIAL SIGNATURE

DD FORM 3005, APR 2019
PREVIOUS EDITION IS OBSOLETE.

24. DATE SIGNED

CUI (when filled in)

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