DD Form 2065 Disposition of Remains - Reimbursable Basis

OMB No. 0704-0030
OMB approval expires:
XXXXXXXX

DISPOSITION OF REMAINS - REIMBURSABLE BASIS
(Read Privacy Act Statement on back before completing form.)

The public reporting burden for this collection of information is estimated to average XX 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 whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil.
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 1.
1. TO: (Recipients and address authorized distribution)

2. NAME OF DECEASED (Last, First, Middle Initial)

3. RELATIONSHIP TO SPONSOR
4. NAME OF SPONSOR (Individual, Agency or Firm)
6. GRADE OF SPONSOR

5. ADDRESS OF SPONSOR (Street, City, State and ZIP Code)

7. SSN OF SPONSOR

I, THE UNDERSIGNED, DESIRE THAT DISPOSITION OF REMAINS BE EFFECTED AS INDICATED BELOW: ;DSSOLFDEOHRSWLRQ
8. OPTION 1
a. Preparation of remains at the Government mortuary and return of remains to a continental United States port of entry in a transfer case.
. I have reimbursed the Government
The port mortuary will furnish the requested services and supplies at a cost of $
in this amount. It is requested that the remains be shipped to the following funeral home:

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DD FORM 2065, 20190508 DRAFT

PREVIOUS EDITION IS OBSOLETE.$Gobe Professional ;

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 the sponsor’s instructions for the remains, cost for necessary services and supplies, and
the name, address, and telephone number of a relative (or other person) in CONUS who may be contacted
concerning the remains, if necessary.
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, failure to furnish the requested information may delay processing and
shipment of remains to final destination.

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DD FORM 2065 (BACK), 20190508 DRAFT

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