Fillable Printable Dd Form 2887, Application For Dod Svc Programs, February 2009

Dd Form 2887, Application For Dod Svc Programs, February 2009

APPLICATION FOR DEPARTMENT OF DEFENSE (DoD) STORED VALUE CARD (SVC) PROGRAMS

PRIVACY ACT STATEMENT

AUTHORITY: P.L. 104-134, Debt Collection and Improvement Act 1996, as amended; Department of Defense Financial Management Regulation (DoDFMR) 7000.14-R, Vol. 5,

Chapter 17; 5 U.S.C. 5514; 31 U.S.C. Sections 1322 and 3720A; 37 U.S.C. Section 1007; 31 CFR 210 and 285; and E.O. 9397.

PRINCIPAL PURPOSE(S): To enroll individuals in DoD Stored Value Card (SVC) programs; to obtain authorization

to initiate debit and credit

entries to individual's accounts; and

to facilitate collection of any delinquent amounts.

ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552(a)(b) of the Privacy Act of 1974, as amended. It may be

disclosed outside of DoD to the U.S. Department of the Treasury, Fiscal and Financial Agents and their contractors involved in providing DoD SVC services. In addition, other

Federal, State, or local government agencies that have identified a need to know may obtain this information for the purpose(s) as identified in the DoD Blanket Routine Uses as

published in the Federal Register.

DISCLOSURE: Disclosure is voluntary; however, failure to furnish the requested information may significantly delay or prevent your participation in the DoD SVC program.

2. RATE, RANK, TITLE 3. FIRST NAME

4. MIDDLE INITIAL

5. LAST NAME

6. SSN 7. PAY GRADE

8. MILITARY BRANCH OR COMPANY NAME

(Contractors)

9. DATE OF BIRTH

(MMDD)

10. MOTHER'S MAIDEN NAME OR KEYWORD

(Required for security purposes)

11.a. MILITARY DUTY ADDRESS (For Navy/Marine Cash include assigned Division, Unit, etc.) OR WORK ADDRESS (Contractors)

12.a. RESIDENCE/PERMANENT ADDRESS

c. CITY d. STATE e. ZIP CODE f. COUNTRY

13. WORK TELEPHONE NUMBER 15. E-MAIL ADDRESS

SECTION IV- AUTHORIZATION TO MAKE DoD SVC TRANSFERS ELECTRONICALLY TO AND FROM MY BANK OR CREDIT UNION ACCOUNT

16.a. BANK OR CREDIT UNION NAME b. CITY c. STATE d. ZIP CODE

17. ABA ROUTING NUMBER (9-digit number) 18. ACCOUNT NUMBER

19. ACCOUNT NAME (Your name as it appears on your account) 20. ACCOUNT TYPE (X one)

21. SIGNATURE 22. DATE SIGNED (YYYYMMMDD)

DD FORM 2887, FEB 2009

I authorize the U.S. Treasury's Financial Agent to initiate debit and credit entries to my bank or credit union account at the financial institution specified above

in order to fulfill any requests I may make to transfer funds between my bank or credit union account and my SVC account.

Adobe Professional 8.0

23. ISSUED BY (Disbursing/Finance Office Name/Location) 24. CARD NUMBER (Last 6 digits)

PREVIOUS EDITION IS OBSOLETE.

CHECKING SAVINGS

DIRECTIONS: Submit completed form to Disbursing or Finance Office or other authorized person coordinating enrollment for DoD-approved SVC program. Provide bank or

credit union information if you wish to transfer funds from your bank or credit union account to your SVC account at an SVC kiosk or cashless ATM. For more information about

DoD SVC programs, please visit http://www.fms.treas.gov/eaglecas

h or http://www.fms.treas.gov/navycash.

1. STORED VALUE CARD (SVC) PROGRAM APPLYING FOR (X as applicable)

EAGLECASH NAVY CASH/MARINE CASH OTHER (Specify)

SECTION I - APPLICANT PERSONAL INFORMATION

b. USMC ONLY

(1) MEU (2) MLG

b. CITY c. STATE d. ZIP CODE e. COUNTRY

14. CELL TELEPHONE NUMBER

SECTION V - FOR OFFICE USE ONLY

SECTION II - APPLICANT BANK OR CREDIT UNION INFORMATION

DEBT COLLECTION/WAIVER OF PRIOR DUE PROCESS: In consideration of receiving a DoD SVC, I hereby knowingly and voluntarily consent to the

immediate collection from my pay (military or civilian DoD pay), without prior notice or prior opportunity for a hearing or review, of any amounts that may

become due and owing as a result of my use of the SVC. This means the government may deduct amounts owed from my pay as authorized by 5 U.S.C.

5514, 37 U.S.C. 1007, and other applicable laws. If I am employed by a contractor or if I am no longer receiving military or civilian pay, and amounts remain

or become due and owing, I understand that the government will initiate debt collection procedures in accordance with the Federal Claims Collection

Standards (31 C.F.R. Parts 900-904) and Chapters 28-32, Volume 5, DoD 7000.14-R, DoD Financial Management Regulation.

EXPIRED, LOST, STOLEN, OR DAMAGED CARD: When my DoD SVC expires, any value remaining will be forwarded to my bank or credit union account

specified above. If the account has been closed or if any value remaining on the SVC cannot be forwarded to the account for an y other reason, I understand

that the funds will be transferred to an account in the U.S. Treasury in accordance with 31 U.S.C. 1322 and that I retain the right to claim such funds. For

Navy Cash/Marine Cash only: If my DoD SVC is lost, stolen, or damaged, I may be charged a fee for a replacement card.

ADDITIONAL TERMS AND CONDITIONS: By using the DoD SVC, I agree to accept the terms and conditions for use of the SVC established by the issuer

of the card. This form may be imaged and kept on file electronically by the U.S. Department of the Treasury and/or its Financial or Fiscal Agent. The

electronic image shall be considered the legal equivalent of the original.

SECTION III - STATEMENTS OF UNDERSTANDING

OMB No. 0730-0016

OMB approval expires

Oct 31, 2011

The public reporting burden for this collection of information is estimated to average 10 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon,

Washington, DC 20301-1155 (0730-0016). 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 COMPLETED FORM TO THE ADDRESS IN THE PARAGRAPH BELOW. SUBMIT COMPLETED FORMS AS SHOWN IN "DIRECTIONS".

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