Get Da 3715 2002

US ARMY NONAPPROPRIATED FUNDS - DISPOSITION OF RETIREMENT BENEFITS For use of this form see AR 215-3 the proponent agency is DCS G1. I request Disability Retirement. I request Survivor Benefits. SECTION III - EMPLOYEE S OR SURVIVOR SIGNATURE 17. SIGNATURE OF EMPLOYEE/SURVIVOR 18. DATE YYYYMMDD SECTION IV - VERIFICATION AND CPU MAILING ADDRESS AND SIGNATURE 19. The above information has been verified from the employee s personnel records and DA Form 3473 coded 04 is attached. a. CPU SIGNATURE c. MAILING ADDRESS 20. AUTHORITY DATA REQUIRED BY THE PRIVACY ACT OF 1974 Internal Revenue Service Code Section 401 a. PRINCIPAL PURPOSE The information you provide is for the purpose of preparing a refund of contribution or to process a retirement annuity. ROUTINE USES For terminating employees the information is used to prepare a refund or a deferred annuity as requested* For retiring employees the information is used to process a monthly annuity payment thereafter. For survivors the information is used to process survivor benefits. DISCLOSURE Disclosure of your social security number and primary insurance amount is voluntary. Disclosure of other personal information is voluntary however failure to provide this information within one year of termination of employment will result in automatic refund of contributions and denial of annuity. SECTION I - GENERAL INFORMATION 2. SOCIAL SECURITY NUMBER 3. DATE OF BIRTH YYYYMMDD 1. EMPLOYEE S NAME Last first MI 4a* COMPLETE MAILING ADDRESS 4b. E-MAIL ADDRESS 5a* AREA CODE/TELEPHONE NUMBER 5b. FAX TELEPHONE NUMBER 6. SERVICE COMPUTATION DATE YYYYMMDD 7. DATE OF SEPARATION AND REASON YYYYMMDD 8. ACCUMULATED SICK LEAVE HOURS 9. EMPLOYING NAF 10. STANDARD NAF NUMBER 11. MARITAL STATUS NOT MARRIED 12. NAME OF LEGAL SPOUSE Last First MI 14. DATE OF BIRTH OF LEGAL SPOUSE 15. DATE OF MARRIAGE YYYYMMDD YYYYMMDD The date of marriage has been verified by satisfactory evidence and the benefit authorized* A certified copy of the Death Certificate and Statement of Survivor s Social Security Entitlements are attached* Annuity Benefits resulting from the death of the employee are payable in accordance with the Army NAF Retirement Plan* SECTION II - RETIREMENT FUND OPTIONS 16. CHECK ONE In accordance with AR 215-3 I request a refund of my contributions and accumulated interest in full satisfaction of all annuity payable. I request my contributions remain in deposit for a maximum of 5 years. I request an immediate Annuity Normal or Early Retirement I request a Deferred Annuity payable at age 62. I request Disability Retirement. I request Survivor Benefits. SECTION III - EMPLOYEE S OR SURVIVOR SIGNATURE 17. SIGNATURE OF EMPLOYEE/SURVIVOR 18. DATE YYYYMMDD SECTION IV - VERIFICATION AND CPU MAILING ADDRESS AND SIGNATURE 19. The above information has been verified from the employee s personnel records and DA Form 3473 coded 04 is attached* a* CPU SIGNATURE c* MAILING ADDRESS 20. DATE RECEIVED YYYYMMDD DA FORM 3715 JAN 2002 DO NOT USE - FOR OFFICIAL USE ONLY 22. PROCESSED BY 21. .