AUTHORITY: E.O. 9397 (SSN).
PRINCIPAL PURPOSE: To be used by civilian employees (current, former, or retired) and military members (active, separated, or retired), and
annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances, and expense reimbursement or
allowances for travel, transportation, and relocation; or in the case of enlisted members, remission of these debts.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the PA, this information may be disclosed to
the Department of Justice or to commercial credit agencies, whenever a financial status report is requested by the Department of Defense (DoD) for
use in administering the Federal Claims Collection Act. It may also be disclosed for any of the blanket routine uses as published in the Federal
Register at the beginning of the DFAS compilation of PA system notices.
DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data, including your Social Security Number, may prevent
consideration of the claim.
WAIVER/REMISSION OF INDEBTEDNESS APPLICATION
(If more space is needed, continue on separate sheet(s). Identify each item by number.)
OMB No. 0730-0009
OMB approval expires
Nov 30, 2008
PRIVACY ACT STATEMENT
1. TYPE OF CLAIM (X one)
REMISSIONWAIVER
Authority for granting waiver: Active/Retired Military - 10 U.S.C. 2774; National Guard - 32 U.S.C. 716; Civilian - 5 U.S.C. 5584;
Annuitant - 10 U.S.C. 1442/1453. Remission: Army - 10 U.S.C. 4837; Navy - 10 U.S.C. 6161; Air Force - 10 U.S.C. 9837.
Note: Remission generally is applicable for active duty enlisted personnel only, see DoDFMR, Volume 7A.
SECTION I - CIVILIAN/MILITARY/RETIREE/ANNUITANT INFORMATION
2. NAME (Last, First, Middle Initial) 3. RANK/GRADE 4. SOCIAL SECURITY NUMBER
5. AGENCY/SERVICE
ARMY
NAVY
AIR FORCE
MARINE CORPS
6. STATUS (X applicable block and provide date (YYYYMMDD) for end of enlistment period (EOE),
retirement (DOR), separation (DOS), or service computation date (SCD), as appropriate.)
ACTIVE
GUARD/RESERVE
RETIRED
EOE:
EOE:
DOR:
7. CURRENT COMPLETE MAILING ADDRESS (Street, City, State,
ZIP Code)
8. PLACE OF ASSIGNMENT OR
EMPLOYMENT
9. TELEPHONE (Include DSN or area code)
a. WORK
b. HOME
10. TYPE OF DEBT OR PAY AND ALLOWANCE ERRONEOUSLY PAID 11. GROSS DEBT AMOUNT
12. STATE THE DATE AND HOW YOU FIRST BECAME AWARE OF DEBT OR ERRONEOUS PAYMENT. (Attach notification, if available.)
13. IF YOU WERE AWARE OF DEBT OR ERRONEOUS PAYMENT, EXPLAIN THE ACTIONS YOU TOOK TO CORRECT SITUATION.
14. REASON FOR REQUESTING WAIVER/REMISSION AND WHY YOU FEEL IT SHOULD BE APPROVED (Financial hardship applies ONLY to
REMISSION and if claimed, a financial statement must be attached.)
16. ATTACH COPIES OF ALL PERTINENT DOCUMENTS (Such as Request for BAH, Statement of Service, Separation Worksheet,
DD Form 214, Travel Voucher, Notification of Personnel Action). (If not available, please explain.)
17.a. IF MILITARY OR CIVILIAN, DID YOU RECEIVE LEAVE AND EARNINGS STATEMENT(S)?
YES
NO
19. I certify the above statements are true and correct to the best of my knowledge. The information presented may be referred to the
appropriate investigating office for verification. I understand the penalty for a false claim is a maximum fine of $10,000 or a maximum
imprisonment of 5 years, or both.
a. SIGNATURE b. JOB TITLE/CAREER FIELD c. DATE SIGNED
DD FORM 2789, MAY 2008
OTHER (Specify)
SEPARATED
DOD CIVILIAN
ANNUITANT
DOS:
SCD:
PREVIOUS EDITION IS OBSOLETE.
c. E-MAIL ADDRESS:
15. FOR ANNUITANTS, PROVIDE NAME, SSN AND DATE DECEASED OF MILITARY MEMBER/SPONSOR.
b. IF MILITARY OR CIVILIAN, DID YOU REQUEST THEM ON EMSS/MYPAY?
c. IF RETIREE OR ANNUITANT, DID YOU RECEIVE AN ACCOUNT STATEMENT?
d. IF RETIREE OR ANNUITANT, DID YOU REVIEW THEM?
YES
NO
YES
NO
YES
NO
18. HAVE YOU FILED FOR A CORRECTION OF MILITARY RECORDS?
YES
NO
(If answer to a. or c. is Yes, attach a copy of statement covering before, during, and after period. If No, explain why.)
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.
SEPARATED MILITARY OR FORMER CIVILIAN EMPLOYEES, RETURN COMPLETED FORM TO: DFAS-IN, DEPT. 3300 (WAIVER/REMISSION),
8899 EAST 56TH STREET, INDIANAPOLIS, IN 46249-3300.
ACTIVE DUTY MILITARY, GUARD/RESERVE, RETIRED OR ANNUITANT PAY RECIPIENTS, CIVILIAN EMPLOYEES, RETURN COMPLETED
FORM TO THE ADDRESS LISTED ON THE DEBT NOTIFICATION LETTER FOR COMPLETION OF BACK SIDE.
Adobe Professional 7.0
The public reporting burden for this collection of information is estimated to average 2 hours 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon,
Washington, DC 20301-1155 (0730-0009). 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.
