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Debt and Claim Forms

Below are list of Debt and Claim forms and tools.

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 a debt repayment plan based on financial circumstances. Debtors have the right to apply for a monthly repayment plan within 30 days of receipt of their debt letter. (Note: Debtors must submit their first payment in the amount that the Debtor is proposing to pay within 30 days from the date of their Debt Notification letter along with the VRA/FHA.)

DFAS Proposed Installment Payment Request
Debtor agrees to the proposed installment repayment amount that DFAS established in the initial Debt Notification letter.
 

  SmartForm: For a step-by-step guide to help complete your DFAS Proposed Installment Payment Request.

  PDF: Download and complete your DFAS Proposed Installment Payment Request in PDF format.
 
Reduced Installment Payment Request
Used by Debtors to apply for different payment arrangements than outlined in the 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.

   PDF: Download and complete your Reduced Installment Payment Request in PDF format.

Waiver Forms:

DD Form 2789 – Waiver/Remission of Indebtedness Application
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. 

   SmartForm: For a step-by-step guide to help complete your DD Form 2789.

   PDF: Download and complete your DD Form 2789 in PDF format.

Hearings Forms:

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.

   PDF: Download and complete your Financial Disclosure Statement in PDF format.

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 loses student enrollment status, beginning the following month payments shall be made in equal monthly installments per month 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.

Page updated April 18, 2022