REIMBURSEMENT REQUEST FOR ADOPTION EXPENSES
(Please read Privacy Act Statement and Instructions on page 3 before completing form.)
SECTION I - MEMBER INFORMATION
1. NAME OF MEMBER
(Last, First, Middle Initial)
2. SSN
a. SINGLE
b. MARRIED
c. DIVORCED
3. MARITAL STATUS
(Check one)
4. PAY GRADE
5. EXPIRATION OF SERVICE DATE
(YYYYMMDD)
6. HOME PHONE NO.
7. WORK PHONE NO.
8. CELL PHONE NO.
9. MEMBER'S BRANCH OF SERVICE
a. AIR FORCE
b. ARMY
c. MARINE CORPS
d. NAVY
10. MEMBER’S COMPONENT
(Check one. Must be serving on active duty orders for 180 days or more of continuous service. If ACTIVE is checked, proceed to Block 12.)
a. ACTIVE
b. RESERVE
c. NATIONAL GUARD
a. ACTIVE DUTY START DATE
b. ACTIVE DUTY END DATE
(YYYYMMDD)
(YYYYMMDD)
11. FOR RESERVE OR NATIONAL GUARD
13. EMAIL ADDRESS
12. CORRESPONDENCE ADDRESS
(Include 9-digit ZIP Code and Apartment number, if applicable)
14. ANY PREVIOUS REIMBURSEMENT
Yes
CLAIMED FROM DOD IN CURRENT
No
CALENDAR YEAR
(Check one)
SECTION II - SPOUSE INFORMATION
(If you are single, please go to Section III.)
15. IS SPOUSE A MEMBER OF THE ARMED FORCES?
(Including the U.S. Coast Guard)
Yes
No
(If "NO" is checked, go to Section III)
17. SSN OF SPOUSE
16. NAME OF SPOUSE
(Last, First, Middle Initial)
(Required only if spouse is a member of the Armed Forces)
18. BRANCH OF SERVICE OF SPOUSE
a. AIR FORCE
b. ARMY
c. MARINE CORPS
d. NAVY
e. COAST GUARD
19. SPOUSE’S COMPONENT
(Check one. If ACTIVE is checked, proceed to Block 21.)
a. ACTIVE
b. RESERVE
c. NATIONAL GUARD
a. ACTIVE DUTY START DATE
b. ACTIVE DUTY END DATE
(YYYYMMDD)
(YYYYMMDD)
20. FOR RESERVE OR NATIONAL GUARD
SECTION III - ELECTRONIC FUND TRANSFER INFORMATION
(RTN must be provided.)
21. ROUTING TRANSIT NUMBER
22. ACCOUNT NUMBER
CHECKING
23. ACCOUNT TYPE
(Check one)
SAVINGS
24. INSTITUTION NAME AND MAILING ADDRESS
(Include 9-digit ZIP Code)
SECTION IV - ADOPTION INFORMATION
(RTN must be provided.)
25. DATE OF HOME STUDY
26. DATE CHILD PLACED
27. DATE ADOPTION FINALIZED
28. STATE OR COUNTRY WHERE
IN HOME
THE ADOPTION WAS FINALIZED
(YYYYMMDD)
(YYYYMMDD)
(YYYYMMDD)
29. NOTES:
a. Members on nonactive duty or members on active duty less than 180 days are not eligible for adoption reimbursement.
b. Reimbursement of adoption expenses may be paid only after the adoption is final, and in the case of foreign adoptions, U.S. citizenship has been granted.
Members who leave active duty before the final adoption decree is granted are not entitled to reimbursement.
c. Reimbursement claims must be submitted no later than 2 years after adoption is finalized or, in the case of foreign adoption, 2 years after U.S. citizenship
is granted, unless an exception exists under DoDI 1341.09, Section 3.2.c. Failure to do so may result in loss of reimbursement benefits.
DD FORM 2675, MAR 2018
DD FORM 2675, MAR 2018
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AEM LiveCycle Designer
REIMBURSEMENT REQUEST FOR ADOPTION EXPENSES
(Please read Privacy Act Statement and Instructions on page 3 before completing form.)
SECTION I - MEMBER INFORMATION
1. NAME OF MEMBER
(Last, First, Middle Initial)
2. SSN
a. SINGLE
b. MARRIED
c. DIVORCED
3. MARITAL STATUS
(Check one)
4. PAY GRADE
5. EXPIRATION OF SERVICE DATE
(YYYYMMDD)
6. HOME PHONE NO.
7. WORK PHONE NO.
8. CELL PHONE NO.
9. MEMBER'S BRANCH OF SERVICE
a. AIR FORCE
b. ARMY
c. MARINE CORPS
d. NAVY
10. MEMBER’S COMPONENT
(Check one. Must be serving on active duty orders for 180 days or more of continuous service. If ACTIVE is checked, proceed to Block 12.)
a. ACTIVE
b. RESERVE
c. NATIONAL GUARD
a. ACTIVE DUTY START DATE
b. ACTIVE DUTY END DATE
(YYYYMMDD)
(YYYYMMDD)
11. FOR RESERVE OR NATIONAL GUARD
13. EMAIL ADDRESS
12. CORRESPONDENCE ADDRESS
(Include 9-digit ZIP Code and Apartment number, if applicable)
14. ANY PREVIOUS REIMBURSEMENT
Yes
CLAIMED FROM DOD IN CURRENT
No
CALENDAR YEAR
(Check one)
SECTION II - SPOUSE INFORMATION
(If you are single, please go to Section III.)
15. IS SPOUSE A MEMBER OF THE ARMED FORCES?
(Including the U.S. Coast Guard)
Yes
No
(If "NO" is checked, go to Section III)
17. SSN OF SPOUSE
16. NAME OF SPOUSE
(Last, First, Middle Initial)
(Required only if spouse is a member of the Armed Forces)
18. BRANCH OF SERVICE OF SPOUSE
a. AIR FORCE
b. ARMY
c. MARINE CORPS
d. NAVY
e. COAST GUARD
19. SPOUSE’S COMPONENT
(Check one. If ACTIVE is checked, proceed to Block 21.)
a. ACTIVE
b. RESERVE
c. NATIONAL GUARD
a. ACTIVE DUTY START DATE
b. ACTIVE DUTY END DATE
(YYYYMMDD)
(YYYYMMDD)
20. FOR RESERVE OR NATIONAL GUARD
SECTION III - ELECTRONIC FUND TRANSFER INFORMATION
(RTN must be provided.)
21. ROUTING TRANSIT NUMBER
22. ACCOUNT NUMBER
CHECKING
23. ACCOUNT TYPE
(Check one)
SAVINGS
24. INSTITUTION NAME AND MAILING ADDRESS
(Include 9-digit ZIP Code)
SECTION IV - ADOPTION INFORMATION
(RTN must be provided.)
25. DATE OF HOME STUDY
26. DATE CHILD PLACED
27. DATE ADOPTION FINALIZED
28. STATE OR COUNTRY WHERE
IN HOME
THE ADOPTION WAS FINALIZED
(YYYYMMDD)
(YYYYMMDD)
(YYYYMMDD)
29. NOTES:
a. Members on nonactive duty or members on active duty less than 180 days are not eligible for adoption reimbursement.
b. Reimbursement of adoption expenses may be paid only after the adoption is final, and in the case of foreign adoptions, U.S. citizenship has been granted.
Members who leave active duty before the final adoption decree is granted are not entitled to reimbursement.
c. Reimbursement claims must be submitted no later than 2 years after adoption is finalized or, in the case of foreign adoption, 2 years after U.S. citizenship
is granted, unless an exception exists under DoDI 1341.09, Section 3.2.c. Failure to do so may result in loss of reimbursement benefits.
DD FORM 2675, MAR 2018
DD FORM 2675, MAR 2018
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AEM LiveCycle Designer
30. NAME OF ADOPTED CHILD
a. DATE OF BIRTH
(Last, First, Middle Initial)
(YYYYMMDD)
MALE
b. SEX
(Check one)
FEMALE
31. ADOPTION ARRANGED BY
(Check one. Documentation attached)
a. A state or local government agency.
b. A nonprofit adoption agency that is authorized by state or local law to place children for adoption.
c. Other source authorized by state or local law to place children for adoption.
32. EXPENSES INCURRED
(Complete as applicable and attach documentation)
a. Public and private agency fees.
b. Placement fees, including fees charged adoptive parents for counseling.
c. Legal fees, including court costs.
d. Medical expenses, including hospital expenses of the biological mother and newborn infant, for medical care furnished the adoptive
child before the adoption, and for physical examinations of the biological mother of the child to be adopted.
e. Temporary foster care charges when such care is required before the placement of the child.
f. Subtotal of expenses listed above.
(Items 32.a. through 32.e.)
g. Amount of reimbursement previously applied for and/or received under any other adoption benefits program administered by the
Federal government or under such program administered by a State or Local government.
h. Total expenses.
(Subtotal Item 32.f. minus any reimbursements in Item 32.g.)
SECTION V - ARMED FORCES MEMBER AFFIRMATION
I affirm that the above information and expenses are true and correct to the best of my knowledge. I understand and agree that reimbursement of expenses is
limited to $2,000 per adopted child with maximum reimbursement of $5,000 in any calendar year to a member, or couple where both spouses are members of
the Armed Forces (including the U.S. Coast Guard). I understand that I am allowed to submit only one reimbursement claim per adoption.
I further affirm that neither I nor my spouse have received a reimbursement under any other adoption benefit program administered by the Federal government
or any state or local government. To the best of my knowledge, I am the only active duty member of the Armed Forces or U.S. Coast Guard claiming
reimbursement of
.
33. MEMBER'S NAME
a. MEMBER'S SIGNATURE
b. DATE SIGNED
(Last, First, Middle Initial)
(YYYYMMDD)
SECTION VI - AUTHORIZATION AND VERIFICATION BY COMMANDING OFFICER
I verify that, based upon information provided and documentation attached, the individual named in Block 1 of this form is serving on orders for active duty for
a minimum of 180 consecutive days and is eligible to apply for reimbursement of adoption expenses, subject to final approval by the Defense Finance and
Accounting Service (DFAS).
34. TITLE OF VERIFYING OFFICIAL
35. NAME
(Commanding Officer or Designee)
(Last, First, Middle Initial)
36. DSN
37. COMMERCIAL TELEPHONE
38. DUTY STATION DELIVERY ADDRESS
(APO/FPO Designation and ZIP Code)
39. SIGNATURE
40. DATE SIGNED
(YYYYMMDD)
DD FORM 2675, MAR 2018
DD FORM 2675, MAR 2018
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AEM LiveCycle Designer
AEM LiveCycle Designer
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1052, Adoption Expenses: reimbursement; (DoDFMR) 7000.14-R, Volume 7A, Appendix A, Department of Defense Financial
Management Regulation, Reimbursement of Adoption Expenses; 5 U.S.C. 301, Departmental Regulation; DoDI 1341.09, DoD Adoption Reimbursement Policy;
and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): Used for reviewing, approving, accounting and disbursing for adoption reimbursement. The Social Security Number (SSN) is used
to maintain a numerical identification system for individual claims and tax reporting purposes.
ROUTINE USE(S): To the Federal Reserve banks to distribute payments made through the direct deposit system to financial organizations or their processing
agents authorized by individuals to receive and deposit payments in their accounts. Other applicable Routine Use(s) are: Law Enforcement Routine Use,
Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use,
and Data Breach Remediation Purposes Routine Use, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/Blanket-Routine-Uses/
The applicable system of records notice is T7347, Adoption Reimbursement System, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/
DODwideSORNArticleView/tabid/6797/Article/570777/t7347.aspx
DISCLOSURE: Voluntary; however, failure to furnish information requested may result in total or partial denial of amount claimed.
APPLICATION PROCESSING INSTRUCTIONS
1. DD Form 2675 must be completed in its entirety, affirmed by the member, and verified by the member's commander or designee. A separate DD Form 2675
must be completed for each child. Assistance in completing this form is available from Military OneSource, 1-800-342-9647, www.militaryonesource.mil or
installation Military and Family Support Centers or Personnel and Finance activities. DFAS will provide any additional guidance needed concerning the
program.
2. The member will provide documentation supporting placement by an authorized source, any final court papers including translations if necessary, all
substantiating receipts in U.S. currency amounts with the claim, and in the case of foreign adoptions, submit proof of U.S. citizenship for the child.
3. If necessary, claim requests and verification forms may be mailed to the Personnel activity. Claim forms may be signed by the member's spouse under a
power of attorney, which must be included in the application packet.
4. The member must retain copies of all paperwork until the claim is paid or denied.
5. When the reimbursement request with documentation is complete, the member's commanding officer, or designee, will verify as to the validity of the claim by
completing Section VI.
6. The completed DD Form 2675 and claim application package with original signatures of both the member and verifying official may be submitted by the
member's command via postal mail to: Defense Finance and Accounting Service, Cleveland Center (Code JFLADA),1240 East Ninth Street, Cleveland, OH
44199. A completed DD Form 2675 that was digitally signed may be submitted by the member or the member's command by postal mail or via DoD
Enterprise (encrypted) email to DFAS-CL Center: dfas.cleveland-oh.jfl.mbx.adoption-reimbursement-cle@mail.mil.
7. If the adoption and expenses are eligible for reimbursement, the Director, DFAS-CL will so certify the payment.
8. DFAS-CL will reimburse by Electronic Funds Transfer (EFT) to the member's EFT account. Upon payment, a letter detailing the reimbursed expenses will be
sent to the member.
9. If eligibility for reimbursement cannot be determined from the documents provided or claimed expenses are not properly supported by receipts, DFAS-CL will
retain the claim and request the necessary information or documentation. The additional documentation must be submitted within 90 days for the claim to be
considered.
10. If the claim is denied, a letter stating the denial will be sent to the member's correspondence address. The claim will not be returned to the member.
11. To obtain detailed requirements, the member should consult DoD 7000.14-R, DODFMR, Volume 7A, Appendix A, "Reimbursement of Adoption Expenses",
found at www.dod.mil/comptroller/fmr. For additional assistance, the member may contact DFAS-CL Adoptions Reimbursement, DSN 580-5576 or
Commercial (216) 522-5576, or Email: dfas.cleveland-oh.jfl.mbx.adoption-reimbursement-cle@mail.mil.
DD FORM 2675, MAR 2018
DD FORM 2675, MAR 2018
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PREVIOUS EDITION IS OBSOLETE.
PREVIOUS EDITION IS OBSOLETE.
AEM LiveCycle Designer
AEM LiveCycle Designer
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