OMB No. 0730-0001
CHILD ANNUITANT'S SCHOOL CERTIFICATION
OMB approval expires
Nov 30, 2008
The public reporting burden for this collection of information is estimated to average 12 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, Executive Services Directorate (0730-0OO1). 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:
Defense Finance and Accounting Service, U.S. Military Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Sections 1435 and 1447; and E.O. 9397.
PRINCIPAL PURPOSE(S): The Defense Finance and Accounting Services (DFAS) uses this information to determine the continued eligibility of
child annuitants who are receiving annuity payments from the Survivor Benefit Plan (SBP) or Reserve Component Survivor Benefit Plan
(RCSBP). Once the child annuitant reaches age 18, it must be verified that the child is attending school full-time in order for DFAS to continue
making the annuity payments.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records, or information
contained therein, may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: to the Internal
Revenue Service, the Department of Veterans Affairs, or trustees or guardians of survivors (children). It may also be disclosed for any of the
"Blanket Routine Uses" as published at the beginning of the DFAS compilation of systems of record notices.
DISCLOSURE: Voluntary; however, if DFAS does not receive this information, the annuity payments will stop.
WARNING
Penalty for presenting false claims or making false statements in connection with claims: Fine of not more than $10,000 or imprisonment
for not more than 5 years, or both (18 U.S.C. 1001).
SECTION I - IDENTIFICATION INFORMATION
1. MEMBER'S SSN
2. MEMBER'S NAME (Last, First, Middle)
3. ANNUITANT'S SSN
4. ANNUITANT'S NAME (Last, First, Middle)
5. IF UNDER AGE OF MAJORITY, NAME OF LEGAL REPRESENTATIVE
SECTION II - STUDENT'S CERTIFICATION (To be completed by child annuitant)
A separate certification will be required for each term/semester in which the school year is divided. Payments to students continue during
an interval between school terms/semesters that does not exceed 150 days if they demonstrate to the satisfaction of the DFAS Center that
they have a bona fide intention of resuming or continuing a full-time course of study or training. Failure to provide a completed certification
form may result in suspension of the annuity.
Please complete this section and have Section III and Section IV (on back) completed by a school official. NOTE: School official may not
certify attendance any earlier than 30 days prior to the end of the school semester. Return all sections of this form to Defense Finance and
Accounting Service, U.S. Military Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300.
6. DATE OF BIRTH (YYYYMMDD)
7. ARE YOU MARRIED? (X one. If YES, attach copy of marriage certificate.)
YES
NO
8. ARE YOU CURRENTLY ATTENDING SCHOOL FULL TIME? (X one. NOTE: If on semester break, X "NO".)
YES (Complete Items 9 and 10 or 9 and 11.)
NO (Go to Item 12.)
9.a. NAME OF SCHOOL
10. IF HIGH SCHOOL, EXPECTED DATE OF COMPLETION
b. ADDRESS (Include ZIP Code)
(YYYYMMDD)
11. IF OTHER THAN HIGH SCHOOL:
a. DATE TERM/SEMESTER
b. DATE TERM/SEMESTER ENDS
BEGAN (YYYYMMDD)
(YYYYMMDD)
c. TELEPHONE NO. (Include Area Code)
(Go to Item 15)
12. IF NOT CURRENTLY ATTENDING SCHOOL FULL TIME:
13. IF HIGH SCHOOL, DATE OF COMPLETION
(YYYYMMDD)
a. NAME OF LAST SCHOOL ATTENDED b. ADDRESS (Include ZIP Code)
14. IF OTHER THAN HIGH SCHOOL:
a. DATE TERM/SEMESTER
b. DATE TERM/SEMESTER ENDED
BEGAN (YYYYMMDD)
(YYYYMMDD)
c. TELEPHONE NO. (Include Area Code)
(Go to Item 15)
15. DO YOU PLAN TO ATTEND SCHOOL FULL TIME DURING THE NEXT 150 DAYS? (X one)
YES (Complete Items 16 through 19.)
NO (Complete Items 18 and 19.)
16.a. NAME OF SCHOOL
17a.
b. ADDRESS (Include ZIP Code)
DATE TERM/
b. DATE TERM/
SEMESTER WILL
SEMESTER WILL
BEGIN (YYYYMMDD)
END (YYYYMMDD)
c. TELEPHONE NO. (Include Area Code)
18. SIGNATURE OF ANNUITANT OR LEGAL REPRESENTATIVE
19. DATE SIGNED
REMEMBER TO OBTAIN
SCHOOL OFFICIAL'S CERTIFICATION
(on back)
DD FORM 2788, NOV 2005
PREVIOUS EDITION IS OBSOLETE.
Reset
Adobe Professional 7.0
OMB No. 0730-0001
CHILD ANNUITANT'S SCHOOL CERTIFICATION
OMB approval expires
Nov 30, 2008
The public reporting burden for this collection of information is estimated to average 12 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, Executive Services Directorate (0730-0OO1). 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:
Defense Finance and Accounting Service, U.S. Military Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Sections 1435 and 1447; and E.O. 9397.
PRINCIPAL PURPOSE(S): The Defense Finance and Accounting Services (DFAS) uses this information to determine the continued eligibility of
child annuitants who are receiving annuity payments from the Survivor Benefit Plan (SBP) or Reserve Component Survivor Benefit Plan
(RCSBP). Once the child annuitant reaches age 18, it must be verified that the child is attending school full-time in order for DFAS to continue
making the annuity payments.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records, or information
contained therein, may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: to the Internal
Revenue Service, the Department of Veterans Affairs, or trustees or guardians of survivors (children). It may also be disclosed for any of the
"Blanket Routine Uses" as published at the beginning of the DFAS compilation of systems of record notices.
DISCLOSURE: Voluntary; however, if DFAS does not receive this information, the annuity payments will stop.
WARNING
Penalty for presenting false claims or making false statements in connection with claims: Fine of not more than $10,000 or imprisonment
for not more than 5 years, or both (18 U.S.C. 1001).
SECTION I - IDENTIFICATION INFORMATION
1. MEMBER'S SSN
2. MEMBER'S NAME (Last, First, Middle)
3. ANNUITANT'S SSN
4. ANNUITANT'S NAME (Last, First, Middle)
5. IF UNDER AGE OF MAJORITY, NAME OF LEGAL REPRESENTATIVE
SECTION II - STUDENT'S CERTIFICATION (To be completed by child annuitant)
A separate certification will be required for each term/semester in which the school year is divided. Payments to students continue during
an interval between school terms/semesters that does not exceed 150 days if they demonstrate to the satisfaction of the DFAS Center that
they have a bona fide intention of resuming or continuing a full-time course of study or training. Failure to provide a completed certification
form may result in suspension of the annuity.
Please complete this section and have Section III and Section IV (on back) completed by a school official. NOTE: School official may not
certify attendance any earlier than 30 days prior to the end of the school semester. Return all sections of this form to Defense Finance and
Accounting Service, U.S. Military Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300.
6. DATE OF BIRTH (YYYYMMDD)
7. ARE YOU MARRIED? (X one. If YES, attach copy of marriage certificate.)
YES
NO
8. ARE YOU CURRENTLY ATTENDING SCHOOL FULL TIME? (X one. NOTE: If on semester break, X "NO".)
YES (Complete Items 9 and 10 or 9 and 11.)
NO (Go to Item 12.)
9.a. NAME OF SCHOOL
10. IF HIGH SCHOOL, EXPECTED DATE OF COMPLETION
b. ADDRESS (Include ZIP Code)
(YYYYMMDD)
11. IF OTHER THAN HIGH SCHOOL:
a. DATE TERM/SEMESTER
b. DATE TERM/SEMESTER ENDS
BEGAN (YYYYMMDD)
(YYYYMMDD)
c. TELEPHONE NO. (Include Area Code)
(Go to Item 15)
12. IF NOT CURRENTLY ATTENDING SCHOOL FULL TIME:
13. IF HIGH SCHOOL, DATE OF COMPLETION
(YYYYMMDD)
a. NAME OF LAST SCHOOL ATTENDED b. ADDRESS (Include ZIP Code)
14. IF OTHER THAN HIGH SCHOOL:
a. DATE TERM/SEMESTER
b. DATE TERM/SEMESTER ENDED
BEGAN (YYYYMMDD)
(YYYYMMDD)
c. TELEPHONE NO. (Include Area Code)
(Go to Item 15)
15. DO YOU PLAN TO ATTEND SCHOOL FULL TIME DURING THE NEXT 150 DAYS? (X one)
YES (Complete Items 16 through 19.)
NO (Complete Items 18 and 19.)
16.a. NAME OF SCHOOL
17a.
b. ADDRESS (Include ZIP Code)
DATE TERM/
b. DATE TERM/
SEMESTER WILL
SEMESTER WILL
BEGIN (YYYYMMDD)
END (YYYYMMDD)
c. TELEPHONE NO. (Include Area Code)
18. SIGNATURE OF ANNUITANT OR LEGAL REPRESENTATIVE
19. DATE SIGNED
REMEMBER TO OBTAIN
SCHOOL OFFICIAL'S CERTIFICATION
(on back)
DD FORM 2788, NOV 2005
PREVIOUS EDITION IS OBSOLETE.
Reset
Adobe Professional 7.0
SECTION III - SCHOOL OFFICIAL'S CERTIFICATION OF CURRENT ATTENDANCE (This section MUST be completed by a school official.)
(NOTE: School official may not certify attendance earlier than 30 days prior to the end of the school semester.)
20. IS THE STUDENT ENROLLED IN A FULL-TIME COURSE OF RESIDENT STUDY OR TRAINING? (Correspondence course does not qualify.
A full-time course of study is a student enrolled on a full-time basis for the entire semester or quarter. If child is not attending full-time,
mark "NO".)
YES (Sections III and IV must be completed)
NO (See Section IV for past attendance)
21. DATE PRESENT SCHOOL TERM
22. TYPE OF EDUCATIONAL INSTITUTION (X one)
a. BEGINS (YYYYMMDD)
b. ENDS (YYYYMMDD)
HIGH SCHOOL
OTHER THAN HIGH SCHOOL
SECTION IV - SCHOOL OFFICIAL'S CERTIFICATION OF PAST ATTENDANCE (This section MUST be completed by a school official.)
23. STUDENT ATTENDED HIGH SCHOOL.
GRADUATION DATE
:
(YYYYMMDD)
24. STUDENT ATTENDED SCHOOL OTHER THAN HIGH SCHOOL FULL-TIME
FOR THE ENTIRE TERM THAT ENDED APPROXIMATELY
:
(YYYYMMDD)
25. STUDENT DID NOT ATTEND SCHOOL. TO THE BEST OF YOUR KNOWLEDGE
THE LAST DAY THE STUDENT ATTENDED SCHOOL FULL-TIME WAS
:
(YYYYMMDD)
26. SCHOOL OFFICIAL
a. NAME (Last, First, Middle Initial)
b. TITLE
c. TELEPHONE NUMBER
(Include Area Code)
d. SIGNATURE
e. DATE SIGNED
27. REMARKS
DD FORM 2788 (BACK), NOV 2005
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