DD Form 2789 Waiver/Remission of Indebtedness Application

What Is DD Form 2789?

DD Form 2789, Waiver/Remission of Indebtedness Application is a form used by current, former, or retired civilian employees and active, separated, or retired service members and annuitants to request a waiver of indebtedness if that indebtedness was caused by an overpayment. In the case of enlisted members, the DD 2789 is filed to request a remission of these debts

The form - sometimes incorrectly referred to as the DA Form 2789 - was released by the Department of Defense (DoD) in May 2008 with all previous editions being obsolete.

The current edition of the form is unclassified and approved for public release. A DD Form 2789 fillable version is available for digital filing and download below or can be found through the Executive Services Directorate website.

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OMB No. 0730-0009
WAIVER/REMISSION OF INDEBTEDNESS APPLICATION
OMB approval expires
(If more space is needed, continue on separate sheet(s). Identify each item by number.)
Nov 30, 2008
The public reporting burden for this collection of information is estimated to average 2 hours 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 (0730-0009). 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.
SEPARATED MILITARY OR FORMER CIVILIAN EMPLOYEES, RETURN COMPLETED FORM TO: DFAS-IN, DEPT. 3300 (WAIVER/REMISSION),
8899 EAST 56TH STREET, INDIANAPOLIS, IN 46249-3300.
ACTIVE DUTY MILITARY, GUARD/RESERVE, RETIRED OR ANNUITANT PAY RECIPIENTS, CIVILIAN EMPLOYEES, RETURN COMPLETED
FORM TO THE ADDRESS LISTED ON THE DEBT NOTIFICATION LETTER FOR COMPLETION OF BACK SIDE.
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9397 (SSN).
PRINCIPAL PURPOSE: To be used by civilian employees (current, former, or retired) and military members (active, separated, or retired), and
annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances, and expense reimbursement or
allowances for travel, transportation, and relocation; or in the case of enlisted members, remission of these debts.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the PA, this information may be disclosed to
the Department of Justice or to commercial credit agencies, whenever a financial status report is requested by the Department of Defense (DoD) for
use in administering the Federal Claims Collection Act. It may also be disclosed for any of the blanket routine uses as published in the Federal
Register at the beginning of the DFAS compilation of PA system notices.
DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data, including your Social Security Number, may prevent
consideration of the claim.
1. TYPE OF CLAIM (X one)
WAIVER
REMISSION
Authority for granting waiver: Active/Retired Military - 10 U.S.C. 2774; National Guard - 32 U.S.C. 716; Civilian - 5 U.S.C. 5584;
Annuitant - 10 U.S.C. 1442/1453. Remission: Army - 10 U.S.C. 4837; Navy - 10 U.S.C. 6161; Air Force - 10 U.S.C. 9837.
Note: Remission generally is applicable for active duty enlisted personnel only, see DoDFMR, Volume 7A.
SECTION I - CIVILIAN/MILITARY/RETIREE/ANNUITANT INFORMATION
2. NAME (Last, First, Middle Initial)
3. RANK/GRADE
4. SOCIAL SECURITY NUMBER
5. AGENCY/SERVICE
6. STATUS (X applicable block and provide date (YYYYMMDD) for end of enlistment period (EOE),
retirement (DOR), separation (DOS), or service computation date (SCD), as appropriate.)
ARMY
OTHER (Specify)
NAVY
ACTIVE
EOE:
SEPARATED
DOS:
AIR FORCE
GUARD/RESERVE
EOE:
DOD CIVILIAN
SCD:
MARINE CORPS
RETIRED
DOR:
ANNUITANT
7. CURRENT COMPLETE MAILING ADDRESS (Street, City, State,
8. PLACE OF ASSIGNMENT OR
9. TELEPHONE
(Include DSN or area code)
ZIP Code)
EMPLOYMENT
a. WORK
b. HOME
c. E-MAIL ADDRESS:
10. TYPE OF DEBT OR PAY AND ALLOWANCE ERRONEOUSLY PAID
11. GROSS DEBT AMOUNT
12. STATE THE DATE AND HOW YOU FIRST BECAME AWARE OF DEBT OR ERRONEOUS PAYMENT. (Attach notification, if available.)
13. IF YOU WERE AWARE OF DEBT OR ERRONEOUS PAYMENT, EXPLAIN THE ACTIONS YOU TOOK TO CORRECT SITUATION.
14. REASON FOR REQUESTING WAIVER/REMISSION AND WHY YOU FEEL IT SHOULD BE APPROVED (Financial hardship applies ONLY to
REMISSION and if claimed, a financial statement must be attached.)
15. FOR ANNUITANTS, PROVIDE NAME, SSN AND DATE DECEASED OF MILITARY MEMBER/SPONSOR.
16. ATTACH COPIES OF ALL PERTINENT DOCUMENTS (Such as Request for BAH, Statement of Service, Separation Worksheet,
DD Form 214, Travel Voucher, Notification of Personnel Action). (If not available, please explain.)
17.a. IF MILITARY OR CIVILIAN, DID YOU RECEIVE LEAVE AND EARNINGS STATEMENT(S)?
YES
NO
b. IF MILITARY OR CIVILIAN, DID YOU REQUEST THEM ON EMSS/MYPAY?
NO
YES
c. IF RETIREE OR ANNUITANT, DID YOU RECEIVE AN ACCOUNT STATEMENT?
YES
NO
d. IF RETIREE OR ANNUITANT, DID YOU REVIEW THEM?
NO
YES
(If answer to a. or c. is Yes, attach a copy of statement covering before, during, and after period. If No, explain why.)
18. HAVE YOU FILED FOR A CORRECTION OF MILITARY RECORDS?
YES
NO
19. I certify the above statements are true and correct to the best of my knowledge. The information presented may be referred to the
appropriate investigating office for verification. I understand the penalty for a false claim is a maximum fine of $10,000 or a maximum
imprisonment of 5 years, or both.
a. SIGNATURE
b. JOB TITLE/CAREER FIELD
c. DATE SIGNED
DD FORM 2789, MAY 2008
Reset
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 7.0
OMB No. 0730-0009
WAIVER/REMISSION OF INDEBTEDNESS APPLICATION
OMB approval expires
(If more space is needed, continue on separate sheet(s). Identify each item by number.)
Nov 30, 2008
The public reporting burden for this collection of information is estimated to average 2 hours 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 (0730-0009). 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.
SEPARATED MILITARY OR FORMER CIVILIAN EMPLOYEES, RETURN COMPLETED FORM TO: DFAS-IN, DEPT. 3300 (WAIVER/REMISSION),
8899 EAST 56TH STREET, INDIANAPOLIS, IN 46249-3300.
ACTIVE DUTY MILITARY, GUARD/RESERVE, RETIRED OR ANNUITANT PAY RECIPIENTS, CIVILIAN EMPLOYEES, RETURN COMPLETED
FORM TO THE ADDRESS LISTED ON THE DEBT NOTIFICATION LETTER FOR COMPLETION OF BACK SIDE.
PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9397 (SSN).
PRINCIPAL PURPOSE: To be used by civilian employees (current, former, or retired) and military members (active, separated, or retired), and
annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances, and expense reimbursement or
allowances for travel, transportation, and relocation; or in the case of enlisted members, remission of these debts.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. Section 552a of the PA, this information may be disclosed to
the Department of Justice or to commercial credit agencies, whenever a financial status report is requested by the Department of Defense (DoD) for
use in administering the Federal Claims Collection Act. It may also be disclosed for any of the blanket routine uses as published in the Federal
Register at the beginning of the DFAS compilation of PA system notices.
DISCLOSURE: Disclosure is voluntary; however, failure to disclose the requested data, including your Social Security Number, may prevent
consideration of the claim.
1. TYPE OF CLAIM (X one)
WAIVER
REMISSION
Authority for granting waiver: Active/Retired Military - 10 U.S.C. 2774; National Guard - 32 U.S.C. 716; Civilian - 5 U.S.C. 5584;
Annuitant - 10 U.S.C. 1442/1453. Remission: Army - 10 U.S.C. 4837; Navy - 10 U.S.C. 6161; Air Force - 10 U.S.C. 9837.
Note: Remission generally is applicable for active duty enlisted personnel only, see DoDFMR, Volume 7A.
SECTION I - CIVILIAN/MILITARY/RETIREE/ANNUITANT INFORMATION
2. NAME (Last, First, Middle Initial)
3. RANK/GRADE
4. SOCIAL SECURITY NUMBER
5. AGENCY/SERVICE
6. STATUS (X applicable block and provide date (YYYYMMDD) for end of enlistment period (EOE),
retirement (DOR), separation (DOS), or service computation date (SCD), as appropriate.)
ARMY
OTHER (Specify)
NAVY
ACTIVE
EOE:
SEPARATED
DOS:
AIR FORCE
GUARD/RESERVE
EOE:
DOD CIVILIAN
SCD:
MARINE CORPS
RETIRED
DOR:
ANNUITANT
7. CURRENT COMPLETE MAILING ADDRESS (Street, City, State,
8. PLACE OF ASSIGNMENT OR
9. TELEPHONE
(Include DSN or area code)
ZIP Code)
EMPLOYMENT
a. WORK
b. HOME
c. E-MAIL ADDRESS:
10. TYPE OF DEBT OR PAY AND ALLOWANCE ERRONEOUSLY PAID
11. GROSS DEBT AMOUNT
12. STATE THE DATE AND HOW YOU FIRST BECAME AWARE OF DEBT OR ERRONEOUS PAYMENT. (Attach notification, if available.)
13. IF YOU WERE AWARE OF DEBT OR ERRONEOUS PAYMENT, EXPLAIN THE ACTIONS YOU TOOK TO CORRECT SITUATION.
14. REASON FOR REQUESTING WAIVER/REMISSION AND WHY YOU FEEL IT SHOULD BE APPROVED (Financial hardship applies ONLY to
REMISSION and if claimed, a financial statement must be attached.)
15. FOR ANNUITANTS, PROVIDE NAME, SSN AND DATE DECEASED OF MILITARY MEMBER/SPONSOR.
16. ATTACH COPIES OF ALL PERTINENT DOCUMENTS (Such as Request for BAH, Statement of Service, Separation Worksheet,
DD Form 214, Travel Voucher, Notification of Personnel Action). (If not available, please explain.)
17.a. IF MILITARY OR CIVILIAN, DID YOU RECEIVE LEAVE AND EARNINGS STATEMENT(S)?
YES
NO
b. IF MILITARY OR CIVILIAN, DID YOU REQUEST THEM ON EMSS/MYPAY?
NO
YES
c. IF RETIREE OR ANNUITANT, DID YOU RECEIVE AN ACCOUNT STATEMENT?
YES
NO
d. IF RETIREE OR ANNUITANT, DID YOU REVIEW THEM?
NO
YES
(If answer to a. or c. is Yes, attach a copy of statement covering before, during, and after period. If No, explain why.)
18. HAVE YOU FILED FOR A CORRECTION OF MILITARY RECORDS?
YES
NO
19. I certify the above statements are true and correct to the best of my knowledge. The information presented may be referred to the
appropriate investigating office for verification. I understand the penalty for a false claim is a maximum fine of $10,000 or a maximum
imprisonment of 5 years, or both.
a. SIGNATURE
b. JOB TITLE/CAREER FIELD
c. DATE SIGNED
DD FORM 2789, MAY 2008
Reset
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 7.0
20. COMMANDER'S ENDORSEMENT (Required for Navy active duty and reserves, others optional. Use separate sheet of paper if needed.)
$
$
21. RECOMMENDATION:
APPROVE
PARTIAL
DENY
RECOMMEND COLLECTION RATE
22a. COMMANDER'S SIGNATURE
b. DATE SIGNED
SECTION II - REPORT OF INVESTIGATION
To be completed and signed by appropriate payroll/travel office. (Not applicable for retirees, annuitants, or out-of-service military members.)
23. INFORMATION ON DEBT OR ERRONEOUS PAYMENT(S)
a. GROSS DEBT AMOUNT
b. TYPE(S) OF PAYMENT(S)
c. DATE(S) OF PAYMENT(S)
YES NO (5) DATE THE DEBT WAS DISCOVERED
d. (X and complete as applicable)
(1) HAS THE DEBT BEEN VALIDATED?
(2) HAS THE DEBT BEEN POSTED TO THE DEBTOR'S RECORDS?
(6) NAVY ONLY: AMOUNT UNCOLLECTED AS OF
DATE OF THE COMMANDER'S SIGNATURE:
(3) REMISSION: HAS THE COLLECTION ACTION BEEN SUSPENDED?
$
(4) WAIVER: HAS FINANCE OFFICE SUSPENDED COLLECTION IAW DODFMR, VOL. 5, CH. 31?
24. A DEBT COMPUTATION MUST ACCOMPANY THIS APPLICATION. It must include dates of erroneous payments, what was paid (broken down
by entitlements), what should have been paid, and the difference. The total debt must equal the debt posted to the debtor's record. Indicate any
entitlements or credits used to offset the debt. This application will be returned without action unless the computation is included.
a. ENTITLEMENT
b. DATE(S)
c. WAS PAID
d. SHOULD HAVE BEEN PAID
e. DIFFERENCE
0.00
0.00
0.00
0.00
25. DETAILED STATEMENT OF HOW AND WHY ERROR OCCURRED.
26. IS THERE ANY INDICATION OF FRAUD, MISREPRESENTATION, FAULT, OR LACK OF GOOD FAITH ON THE PART OF THE CLAIMANT?
NO
YES (Explain)
27. STATEMENT AS TO WHETHER OR NOT THE CLAIMANT KNEW OR SHOULD HAVE BEEN AWARE OF RECEIVING AN ERRONEOUS
PAYMENT. (Furnish facts and circumstances to support answer, state whether claimant received documents, and provide copies, if
available. Use a separate sheet of paper if additional space is required.)
28. REMARKS (Attach a separate sheet of paper, if needed.)
$
29. RECOMMENDATION:
APPROVE
PARTIAL
DENY
30. DESIGNATED FINANCIAL AGENT
a. SIGNATURE
b. TITLE
c. DATE SIGNED
31a. COMPLETE UNIT MAILING ADDRESS
b. POINT OF CONTACT NAME
c. TELEPHONE (DSN)
d. FAX NUMBER
e. ADSN/DSSN/UIC
f. E-MAIL ADDRESS
DD FORM 2789 (BACK), MAY 2008
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How to Fill out DD Form 2789?

The form is made up of two pages with no filing guidelines provided by the DoD. DD Form 2789 instructions are as follows:

  1. The type of claim identified in Block 1 should always be "Waiver". Remission is only applicable to active duty enlisted personnel (see DoDFMR, Volume 7A for more information);
  2. The claimant has to provide their full name, rank or grade and social security number in Blocks 2 through 4;
  3. Block 5 is for specifying the claimants' branch of service. Annuitants should check the "Other" box and specify their annuitant status;
  4. Block 6 requires the claimants status;
  5. The current mailing address of the claimant should be in Block 7. Annuitants and retirees should write N/A in Block 8, others should provide their place of assignment or employment. Block 9 is for specifying the applicant's work and home phone numbers and email address;
  6. The type of debt or pay should be specified in Block 10. The gross debt amount is entered in Block 11;
  7. The date and the consequences in which the claimant found out about the debt should be identified in Block 12. A notification or any additional documentation can be attached of needed;
  8. If the claimant was aware of the debt, they should provide the actions they took to correct the situation in Block 13;
  9. Any reasons for the request to be approved are provided in Block 14. Any supporting documentation must be attached to the form;
  10. Annuitants should fill Block 15 with name, social security number, and date deceased of military member or sponsor;
  11. All supporting documentation for Blocks 12 through 14 should be listed in Block 16;
  12. Block 17 contains a set of questions with yes-or-no answers. Negative answers should be explained;
  13. Block 18 specifies whether the claimant has requested military records correction;
  14. The claimant provides their signature, the date of filing the form and their job title in Block 19;
  15. Blocks 20 through 22 and the entire Section II - Report of Investigation - are for administrative use only.
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