DD Form 2840 Request for Information Regarding Deceased Debtor

CUI (when filled in)
OMB No. 0730-0015
OMB approval expires
20240630

REQUEST FOR INFORMATION REGARDING DECEASED DEBTOR

PLEASE DO NOT RETURN YOUR FORM TO THE ORGANIZATION IN THE PARAGRAPH BELOW.
RETURN COMPLETED FORM TO: DEFENSE FINANCE AND ACCOUNTING SERVICES, 8899 EAST 56TH STREET, DEPARTMENT 3300
(ATTN: CUSTOMER OPERATIONS), INDIANAPOLIS, IN 46249-3300
The public reporting burden for this collection of information is estimated to average 5 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.

PRIVACY ACT STATEMENT
AUTHORITY: 31 U.S.C. Section 3111; P.L. 102-484, Sec. 614; Department of Defense Financial Management Regulation (DoDFMR) 7000.14-R, Vol. 5; E.O.
9397 (SSN).
PRINCIPAL PURPOSE(S): To seek information from state probate courts or executors of the deceased members' estates concerning the establishment of an
estate and to pursue collection of the indebtedness from the estate, as appropriate.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. 552a(b) of the Privacy Act. The "Blanket Routine Uses"
published at the beginning of the DoD compilation of systems of records notices also apply.
DISCLOSURE: Voluntary; however, if the information is not provided, it may cause a delay in the settlement of the debt owed by the member's estate.
1. DECEASED DEBTOR
a. NAME (Last, First, Middle)

b. SSN

c. HOME OF RECORD

The deceased debtor named above was indebted to the United States at the time of death. Please complete items below and return this
form. Your assistance is appreciated.

NEEDS DD67

2. DATE OF REQUEST (YYYYMMDD) 3a. SIGNATURE OF REQUESTOR

b. PRINTED NAME

c. TITLE

d. GRADE

4. WAS AN ESTATE ESTABLISHED?

NO
YES (If Yes, complete Items 5 and 6 below)
5. NAME AND ADDRESS OF ATTORNEY, ADMINISTRATOR, OR EXECUTOR

6. ARE ANY OF THE INDIVIDUALS AT LEFT MEMBERS OF THE
IMMEDIATE FAMILY (Please specify)

7. ARE SPECIAL CLAIM FORMS AVAILABLE?
YES (If Yes, please provide)
8. REMARKS

9a. NAME OF INDIVIDUAL COMPLETING FORM

DD FORM 2840, DRAFT 20240604
PREVIOUS EDITION IS OBSOLETE.

NO

b. SIGNATURE

CUI (when filled in)

c. DATE (YYYYMMDD)

Controlled by: DFAS
Reset
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: dfas.indianapolis-in.zed.mbx.info-management-control-officer@mail.mil