DA Form 5521 Record of Emergency Data and Designation of Beneficiary for Unpaid Compensation of Deceased Naf Employee

DA Form 5521 or the "Record Of Emergency Data And Designation Of Beneficiary For Unpaid Compensation Of Deceased Naf Employee" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 5521 - was last revised on October 1, 2001. Download an up-to-date fillable DA Form 5521 down below in PDF-format or look it up on the Army Publishing Directorate website.

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RECORD OF EMERGENCY DATA AND DESIGNATION OF BENEFICIARY FOR
UNPAID COMPENSATION OF DECEASED NAF EMPLOYEE
For use of this form, see AR 215-3; the proponent agency is DCS, G1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
10 USC 3012.
AUTHORITY:
Obtain emergency data from NAF employees, obtain legal designation of beneficiary for unpaid compensation payable to the
PRINCIPAL PURPOSE:
estate of a deceased employee.
Inform appropriate authorities of name and address of individual to be notified in the event of emergency or death of NAF
ROUTINE USES:
employee; inform NAF payroll office to whom and where to send unpaid compensation due.
DISCLOSURE:
Mandatory. Failure to provide this information may result in a delay of payment of unpaid compensation of the deceased NAF
employee and may result in payment to the estate of the decedent rather than payment to the beneficiary of the decedent's
choice.
PART A - EMERGENCY DATA
1. EMPLOYING NAFI ACTIVITY
2. EMPLOYEE'S NAME (First, Middle, Last)
3. DOB (YYYYMMDD)
4. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (Name, Address, and E-Mail Address)
5. TELEPHONE NO.
(Include area code)
6. PERSON DESIGNATED TO HANDLE ESTATE IN EVENT OF DEATH (Name, Address, and E-Mail)
7. TELEPHONE NO.
(Include area code)
PART B - DESIGNATION OF BENEFICIARY
I, the employee identified above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now designate the
beneficiary (ies) named below to receive any UNPAID COMPENSATIONS due and payable under existing law after my death. I understand that
this Designation of Beneficiary will remain in full force and effect, unless or until cancelled by me in writing, so long as I am continuously
employed in the above-named department or agency.
1. BENEFICIARY (ies) (Type or Print)
2. ADDRESS OF BENEFICIARY
4. PERCENT TO BE PAID
3. RELATIONSHIP
(First, Middle Initial, Last)
(Type or Print)
EACH BENEFICIARY
NAME
SSN
NAME
SSN
I hereby direct unless otherwise indicated above, that if more than one beneficiary is named, the share of any deceased beneficiary who may predecease
me shall be distributed equally among the surviving beneficiaries, or entirely to the survivor. I understand that this designation of beneficiary shall be void if
none of the designated beneficiaries is living at the time of my death. I hereby specifically reserve the right to cancel or change any designation of
beneficiary at any time and without knowledge or consent of the beneficiary.
5. SIGNATURE OF EMPLOYEE
6. DATE OF EXECUTION (YYYYMMDD)
7. WITNESS NAME AND ADDRESS (Typed)
8. TELEPHONE NO. (Include area code)
9. NAME, TITLE, AND SIGNATURE OF AUTHORIZING OFFICIAL
10. DATE OF EXECUTION (YYYYMMDD)
DA FORM 5521-R, JUN 90, IS OBSOLETE.
DA FORM 5521, OCT 2001
APD LC v2.03ES
RECORD OF EMERGENCY DATA AND DESIGNATION OF BENEFICIARY FOR
UNPAID COMPENSATION OF DECEASED NAF EMPLOYEE
For use of this form, see AR 215-3; the proponent agency is DCS, G1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
10 USC 3012.
AUTHORITY:
Obtain emergency data from NAF employees, obtain legal designation of beneficiary for unpaid compensation payable to the
PRINCIPAL PURPOSE:
estate of a deceased employee.
Inform appropriate authorities of name and address of individual to be notified in the event of emergency or death of NAF
ROUTINE USES:
employee; inform NAF payroll office to whom and where to send unpaid compensation due.
DISCLOSURE:
Mandatory. Failure to provide this information may result in a delay of payment of unpaid compensation of the deceased NAF
employee and may result in payment to the estate of the decedent rather than payment to the beneficiary of the decedent's
choice.
PART A - EMERGENCY DATA
1. EMPLOYING NAFI ACTIVITY
2. EMPLOYEE'S NAME (First, Middle, Last)
3. DOB (YYYYMMDD)
4. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (Name, Address, and E-Mail Address)
5. TELEPHONE NO.
(Include area code)
6. PERSON DESIGNATED TO HANDLE ESTATE IN EVENT OF DEATH (Name, Address, and E-Mail)
7. TELEPHONE NO.
(Include area code)
PART B - DESIGNATION OF BENEFICIARY
I, the employee identified above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now designate the
beneficiary (ies) named below to receive any UNPAID COMPENSATIONS due and payable under existing law after my death. I understand that
this Designation of Beneficiary will remain in full force and effect, unless or until cancelled by me in writing, so long as I am continuously
employed in the above-named department or agency.
1. BENEFICIARY (ies) (Type or Print)
2. ADDRESS OF BENEFICIARY
4. PERCENT TO BE PAID
3. RELATIONSHIP
(First, Middle Initial, Last)
(Type or Print)
EACH BENEFICIARY
NAME
SSN
NAME
SSN
I hereby direct unless otherwise indicated above, that if more than one beneficiary is named, the share of any deceased beneficiary who may predecease
me shall be distributed equally among the surviving beneficiaries, or entirely to the survivor. I understand that this designation of beneficiary shall be void if
none of the designated beneficiaries is living at the time of my death. I hereby specifically reserve the right to cancel or change any designation of
beneficiary at any time and without knowledge or consent of the beneficiary.
5. SIGNATURE OF EMPLOYEE
6. DATE OF EXECUTION (YYYYMMDD)
7. WITNESS NAME AND ADDRESS (Typed)
8. TELEPHONE NO. (Include area code)
9. NAME, TITLE, AND SIGNATURE OF AUTHORIZING OFFICIAL
10. DATE OF EXECUTION (YYYYMMDD)
DA FORM 5521-R, JUN 90, IS OBSOLETE.
DA FORM 5521, OCT 2001
APD LC v2.03ES

Download DA Form 5521 Record of Emergency Data and Designation of Beneficiary for Unpaid Compensation of Deceased Naf Employee

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