Statement of Personal Injury: Possible Third Party Liability

OMB 0720-0003

This information is completed by TRICARE beneficiaries suffering from personal injuries and receiving medical care at Government expense. This information is necessary in the assertion of the Government's right to recover under the Federal Medical Care Recovery Act. The data is used in the evaluation and processing of these claims.

The latest form for Statement of Personal Injury: Possible Third Party Liability expires 2022-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form DD Form 2527 Statement of Personal Injury: Possible Third Party Liability Form
0720-0003_SSNJ Memo_2020.pdf Supplementary Document
0720-0003_SSA_4.29.22.docx Supporting Statement A
Statement of Personal Injury: Possible Third Party Liability Form

All Historical Document Collections

202203-0720-005 Approved without change	Extension without change of a currently approved collection	2022-04-29
201902-0720-001 Approved without change	Extension without change of a currently approved collection	2019-02-28
201510-0720-002 Approved without change	Reinstatement with change of a previously approved collection	2015-10-30
201207-0720-002 Approved without change	Reinstatement without change of a previously approved collection	2012-07-05
200708-0720-001 Approved without change	Extension without change of a currently approved collection	2007-08-31
200403-0720-003 Approved with change	Reinstatement with change of a previously approved collection	2004-03-24
199904-0720-001 Approved without change	Reinstatement with change of a previously approved collection	1999-04-28
199408-0720-001 Approved without change	Reinstatement with change of a previously approved collection	1994-08-08
199108-0720-001 Approved without change	Extension without change of a currently approved collection	1991-08-12