DA Form 5521 PDF Details

Understanding the importance of accurately managing emergency data and ensuring the rightful designation of beneficiaries for unpaid compensation is crucial for Non-Appropriated Fund (NAF) employees. This critical process is facilitated through the DA Form 5521, a document that serves multiple essential purposes. Primarily, it is designed to collect emergency contact information and to legally designate one or more beneficiaries for any unpaid compensation that might be due in the event of an employee's untimely death. The form is part of administrative procedures outlined in AR 215-3, with its use mandated by the Privacy Act of 1974, indicating its legal significance and the necessity for its completion. Failure to fill out this form could delay payments to a deceased employee's estate or result in compensation being distributed contrary to the employee's wishes. The form is comprehensive, covering aspects from basic employee information, emergency contact details, to the explicit nomination of beneficiaries, including their relationship and the proportion of compensation they are to receive. This document is a linchpin in ensuring that, in moments of crisis or following an employee's death, their final wishes are respected and that those designated by the employee are promptly informed and compensated accordingly.

QuestionAnswer
Form NameDA Form 5521
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesda form 5521 fillable, da data designation fillable, form 5521, da data designation

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RECORD OF EMERGENCY DATA AND DESIGNATION OF BENEFICIARY FOR

 

UNPAID COMPENSATION OF DECEASED NAF EMPLOYEE

 

For use of this form, see AR 215-3; the proponent agency is DCS, G1.

 

 

 

 

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

AUTHORITY:

10 USC 3012.

 

PRINCIPAL PURPOSE:

Obtain emergency data from NAF employees, obtain legal designation of beneficiary for unpaid compensation payable

 

to the estate of a deceased employee.

 

ROUTINE USES:

Inform appropriate authorities of name and address of individual to be notified in the event of emergency or death of

 

NAF employee; inform NAF payroll office to whom and where to send unpaid compensation due.

DISCLOSURE:

Mandatory. Failure to provide this information may result in a delay of payment of unpaid compensation of the

 

deceased NAF employee and may result in payment to the estate of the decedent rather than payment to the

 

beneficiary of the decedent's choice.

 

 

 

 

 

PART A - EMERGENCY DATA

 

 

 

 

1. EMPLOYING NAFI ACTIVITY

 

 

 

 

2. EMPLOYEE'S NAME (First, Middle, Last)

3. DOB (YYYYMMDD)

 

 

 

4. PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (Name, Address, and E-Mail Address)

5. TELEPHONE NO.

 

 

(Include area code)

6. PERSON DESIGNATED TO HANDLE ESTATE IN EVENT OF DEATH (Name, Address, and E-Mail)

7.TELEPHONE NO.

(Include area code)

PART B - DESIGNATION OF BENEFICIARY

I, the employee identified above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now designate the beneficiary(ies) named below to receive any UNPAID COMPENSATIONS due and payable under existing law after my death. I understand that this Designation of Beneficiary will remain in full force and effect, unless or until cancelled by me in writing, so long as I am continuously employed in the above-named department or agency.

1. BENEFICIARY(ies) (Type or Print)

2. ADDRESS OF BENEFICIARY

3. RELATIONSHIP

4. PERCENT TO BE PAID

(First, Middle Initial, Last)

(Type or Print)

 

EACH BENEFICIARY

 

 

 

 

NAME

 

 

 

SSN

 

 

 

 

 

 

 

NAME

 

 

 

SSN

 

 

 

 

 

 

 

I hereby direct unless otherwise indicated above, that if more than one beneficiary is named, the share of any deceased beneficiary who may predecease me shall be distributed equally among the surviving beneficiaries, or entirely to the survivor. I understand that this designation of beneficiary shall be void if none of the designated beneficiaries is living at the time of my death. I hereby specifically reserve the right to cancel or change any designation of beneficiary at any time and without knowledge or consent of the beneficiary.

5. SIGNATURE OF EMPLOYEE

6. DATE OF EXECUTION (YYYYMMDD)

7. WITNESS NAME AND ADDRESS (Typed)

8.TELEPHONE NO. (Include area code)

9. NAME, TITLE, AND SIGNATURE OF AUTHORIZING OFFICIAL

10. DATE OF EXECUTION (YYYYMMDD)

DA FORM 5521, OCT 2001

DA FORM 5521-R, JUN 90, IS OBSOLETE.

USAPA V2.02ES

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2. The third stage is to fill in the next few blank fields: NAME, SSN, I hereby direct unless otherwise, SIGNATURE OF EMPLOYEE, DATE OF EXECUTION YYYYMMDD, WITNESS NAME AND ADDRESS Typed, TELEPHONE NO Include area code, NAME TITLE AND SIGNATURE OF, DATE OF EXECUTION YYYYMMDD, DA FORM OCT, DA FORM R JUN IS OBSOLETE, and USAPA VES.

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