Debt and Claim Forms
IMPORTANT NOTE TO ALL CUSTOMERS:
If you have issues accessing a form, complete the following:
- Right click on the link
- Select ‘Save Link As’ or ‘Save To’ (dependent on browser)
- Save to your desired location on your computer
- Open the form on your computer
Debt Repayment Forms (Voluntary Repayment / Financial Hardship Application (VRA/FHA)):
Used by debtors/claimants that are unable to pay their debt in a lump sump payment to apply for an installment payment based on financial circumstances. Debtors have the right to apply for a monthly repayment plan within 30 days of receipt of their demand (debt) notification letter. (Note: Debtors must submit their first payment in the amount identified option 1 of the demand (debt) notification letter within along with the VRA/FHA.)
Installment Payment Request
Debtor agrees to the installment repayment amount established in Option 1 the initial demand (debt) notification letter.
SmartForm: For a step-by-step guide to help complete your Installment Payment Request, click here.
Fillable PDF: Download and complete your Installment Payment Request in PDF format, click here.
Reduced Installment Payment Request
Used by Debtors to apply for different payment arrangements than outlined in the demand (debt) notification letter if the payment at the monthly rate shown on the initial account statement would result in extreme financial hardship.
SmartForm: For a step-by-step guide to help complete your Reduced Installment Payment Request, click here.
Fillable PDF: Download and complete your Reduced Installment Payment Request in PDF format, click here.
DD Form 2789 – Waiver/Remission of Indebtedness Application
Used by civilian employees (current, former, or retired), military members (active, separated or retired), and annuitants to request waiver of indebtedness collection for erroneous payments of salary or pay and allowances.
SmartForm: For a step-by-step guide to help complete your DD Form 2789, click here.
Fillable PDF: Download and complete your DD Form 2789 in PDF format, click here.
Request for Administrative Wage Garnishment Hearing
Financial Disclosure Statement
Used by debtors/claimants to claim their finances and expenses to contest a proposed garnishment amount of a debt. To evaluate the hardship claim, the debtor/claimant’s claimed finances and expenses (and support) are compared against averages spent for those similar expenses by families of the same size and income as the debtor/claimant. The Financial Disclosure Statement should be submitted in support of an “Administrative Wage Garnishment Request for Hearing or Eligibility Determination statement.”
SmartForm: For a step-by-step guide to help complete your Financial Disclosure Statement, click here.
Fillable PDF: Download and complete your Financial Disclosure Statement in PDF format, click here.
Student Deferment (Education Debt Only):
Promissory Note for Student Deferment
Used by debtors/claimants to requests a student deferment (no payments) for the repayment of an educational debt/student loan until date of graduation or completion of residency plus 90 days. Once debtors/claimant lose student enrollment status, beginning the following month payments shall be made in equal monthly installments until the entire debt, including interest, late payment penalties, and administrative charges, is paid in full.
PDF: Download and complete your Promissory Note for Student Deferment in PDF format, click here
Correction of Military Record
DD Form 149 - Application for Correction of Military Record
The form is for Board Members to review pertinent information in making a determination of relief through correction of a military record.
PDF: Download and complete your DD Form 149 in PDF format, click here.
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Page updated July 8, 2023