[PDF] LEGAL REPRESENTATIVE: ANNT: SSN: A Certificate of Eligibility





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:
C

ERTIFICATE OF ELIGIBILITY

MBR: SSN:

LEGAL REPRESENTATIVE: ANNT:

SSN: A Certificate of Eligibility (COE) is required annually from each annuitant. To prevent a delay in receiving y our an nuity p ayments please COMPLETE, SIGN and RETURN this COE immediately to

DFAS Retired and Annuitant Pay, . If you have any

questions, call toll-free at 1-800-321-1080 or use our toll free FAX 1-800-982-8459.

I certify that I am the annuitant or the annuitant"s legal representative (custodian, trustee, guardian, legal

fiduciary, or power of attorney) and the information given is correct. I will promptly notify DFAS, at the

above address, if any change occurs in my (the annuitant"s) marital status or if I (the legal representative)

have knowledge the annuitant is deceased. If this COE is signed by a legal representative for the first

time, a photocopy of the legal document must be attached. Signature: Date:

Please check the appropriate boxes below.

New Street Address __________________________________________________________________ City, State, Zip Code __________________________________________________________________

NOTE: Penalty for presenting false claims or making false statements in connection with claims: Fine of not more

than $10,000 on imprisonment for not more than

5 years, or both (18 USC 1001). PRIVACY ACT STATEMENT:

AUTHORITY 37 USC, Chapter 11, EO 9397, Nov 1943. PRINCIPAL PURPOSE: This information is used to determine the continued eligibility of the annuitant for annuity payments.

ROUTINE USES:

Records from this

system of records may be disclosed to the Department of Veterans Affairs (VA).

DISCLOSURE: Disclosure is

voluntary; however, failure to provide information will result in suspension of annuity payments.quotesdbs_dbs43.pdfusesText_43
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