DA Form 7500 Tort Claim Payment Report

DA Form 7500 - also known as the "Tort Claim Payment Report" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 7500 - was last revised on June 1, 2003. Download an up-to-date fillable PDF version of the DA 7500 below or request a copy through the chain of command.

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TORT CLAIM PAYMENT REPORT
For use of this form see DA PAM 27-162; the proponent agency is OTJAG.
A SEPARATE PAYMENT REPORT MUST BE COMPLETED FOR EACH CLAIMANT
1. TO: DFAS, DSSN
2. DATE (YYYYMMDD)
SECTION A - PAYMENT DATA
3. SUBMITTING AGENCY/OFFICE
4. OFFICE CODE
5. AGENCY/OFFICE MAILING ADDRESS
6. DATE CLAIM FILED (YYYYMMDD)
7. CLAIM NUMBER(S)
8. AMOUNT CLAIMED
9. FUND CITE
10. PAYEE
11. ADDRESS
12. SSN OR TAX IDENTIFICATION NUMBER
13. PAYMENT AMOUNT
14. TYPE OF PAYMENT
FOR EFT PAYMENTS
15. ABA ROUTING NUMBER
16. ACCOUNT NAME AND NUMBER
17. NAME AND ADDRESS OF FINANCIAL INSTITUTION
18. ACCOUNT (Check appropriate account)
CHECKING
SAVINGS
SECTION B - ACCEPTANCE BY CLAIMANT
(This form should not be signed by the claimant if another release is signed by the claimant and attached)
I, the claimant, do hereby accept the within-stated award, compromise, or settlement as final and conclusive on my heirs, executors, administrators or assigns, and agree
that said acceptance constitutes a complete release by me, my heirs, executors, administrators or assigns of any and all claims, demands, rights, and causes of action of
whatsoever kind and nature, arising now or in the future from, and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries
(including wrongful death), damages to property, breaches of contract or law, and any other acts or omissions, and the consequences therefrom resulting, and to result,
from the same subject matter that gave rise to the claim for which I or my heirs, executors, administrators, or assigns, and each of them, now have or may hereafter
acquire against the United States and against the employee(s) of the Government whose acts or omissions gave rise to the claim by reason of the same subject matter. I
further agree to reimburse, indemnify and hold harmless the United States, its agents, servants and employees from any and all claims or causes of action, including
wrongful deaths, that arise or may arise from the acts or omissions that gave rise to the claim(s) by reason of the same subject matter.
19. SIGNATURE OF CLAIMANT
20. DATE (YYYYMMDD)
SECTION C - AGENCY CERTIFYING OFFICER
Pursuant to authority vested in me, I certify that this Payment Report is correct and proper for payment.
21. SIGNATURE OF AUTHORIZED CERTIFYING OFFICER
22. DATE (YYYYMMDD)
23. TITLE
24. DATE PAYMENT RECORDED IN CLAIM RECORD
(YYYYMMDD)
DA FORM 7500, JUN 2003
APD LC v1.00
TORT CLAIM PAYMENT REPORT
For use of this form see DA PAM 27-162; the proponent agency is OTJAG.
A SEPARATE PAYMENT REPORT MUST BE COMPLETED FOR EACH CLAIMANT
1. TO: DFAS, DSSN
2. DATE (YYYYMMDD)
SECTION A - PAYMENT DATA
3. SUBMITTING AGENCY/OFFICE
4. OFFICE CODE
5. AGENCY/OFFICE MAILING ADDRESS
6. DATE CLAIM FILED (YYYYMMDD)
7. CLAIM NUMBER(S)
8. AMOUNT CLAIMED
9. FUND CITE
10. PAYEE
11. ADDRESS
12. SSN OR TAX IDENTIFICATION NUMBER
13. PAYMENT AMOUNT
14. TYPE OF PAYMENT
FOR EFT PAYMENTS
15. ABA ROUTING NUMBER
16. ACCOUNT NAME AND NUMBER
17. NAME AND ADDRESS OF FINANCIAL INSTITUTION
18. ACCOUNT (Check appropriate account)
CHECKING
SAVINGS
SECTION B - ACCEPTANCE BY CLAIMANT
(This form should not be signed by the claimant if another release is signed by the claimant and attached)
I, the claimant, do hereby accept the within-stated award, compromise, or settlement as final and conclusive on my heirs, executors, administrators or assigns, and agree
that said acceptance constitutes a complete release by me, my heirs, executors, administrators or assigns of any and all claims, demands, rights, and causes of action of
whatsoever kind and nature, arising now or in the future from, and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries
(including wrongful death), damages to property, breaches of contract or law, and any other acts or omissions, and the consequences therefrom resulting, and to result,
from the same subject matter that gave rise to the claim for which I or my heirs, executors, administrators, or assigns, and each of them, now have or may hereafter
acquire against the United States and against the employee(s) of the Government whose acts or omissions gave rise to the claim by reason of the same subject matter. I
further agree to reimburse, indemnify and hold harmless the United States, its agents, servants and employees from any and all claims or causes of action, including
wrongful deaths, that arise or may arise from the acts or omissions that gave rise to the claim(s) by reason of the same subject matter.
19. SIGNATURE OF CLAIMANT
20. DATE (YYYYMMDD)
SECTION C - AGENCY CERTIFYING OFFICER
Pursuant to authority vested in me, I certify that this Payment Report is correct and proper for payment.
21. SIGNATURE OF AUTHORIZED CERTIFYING OFFICER
22. DATE (YYYYMMDD)
23. TITLE
24. DATE PAYMENT RECORDED IN CLAIM RECORD
(YYYYMMDD)
DA FORM 7500, JUN 2003
APD LC v1.00

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