DA Form 5521 at a glance
What it is: This form is the Record of Emergency Data and Designation of Beneficiary for Unpaid Compensation of Deceased NAF Employee. For use of this form: AR 215-3; the proponent is DCS, G1.
Who signs: In Part B, Box 5, the employee signs, and in Box 10 the authorizing official signs.
A filled-in DA Form 5521 example: an employee names four beneficiaries
How to fill out DA Form 5521, box by box
Part A: employing NAFI activity, employee's name and DOB
Enter the employing NAFI activity in Box 1.
Enter the employee's name (First, Middle, Last) in Box 2 and the DOB (YYYYMMDD) in Box 3.
Person to be notified and person designated to handle estate
In Box 4, enter the person to be notified in case of emergency (Name, Address, and E-Mail Address), and in Box 5 the telephone number (Include area code).
In Box 6, enter the person designated to handle estate in event of death (Name, Address, and E-Mail), and in Box 7 the telephone number (Include area code).
Part B: designation of beneficiary
In Part B, the employee designates the beneficiary (ies) named to receive any unpaid compensations due and payable under existing law after the employee's death, canceling any and all previous Designations of Beneficiary. The Designation of Beneficiary will remain in full force and effect, unless or until cancelled by the employee in writing, so long as the employee is continuously employed in the named department or agency.
For each beneficiary (Type or Print), enter the name (First, Middle Initial, Last), the address of beneficiary, the relationship and the percent to be paid each beneficiary.
Unless otherwise indicated, 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. This designation of beneficiary shall be void if none of the designated beneficiaries is living at the time of my death. I specifically reserve the right to cancel or change any designation of beneficiary at any time and without knowledge or consent of the beneficiary.
Signature of employee and witness
The employee signs the signature of employee in Box 5 and enters the date of execution (YYYYMMDD) in Box 6.
In Part B, Box 7, enter the witness name and address (Typed), and in Box 8 the telephone number (Include area code).
Authorizing official
In Part B, Box 9, enter the name, title, authorizing official. In Box 10, the authorizing official signs the signature of authorizing official, and in Box 11 enters the date of execution (YYYYMMDD).
More rules for DA Form 5521
To obtain emergency contact information from NAF employees, and to obtain legal designation of beneficiary for unpaid compensation payable to the estate of a deceased employee. See the Systems of Records Notice A0215-3 NAF Personnel Records.
Providing this information is voluntary, however failure to provide it 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.
Sources
[1] DA Form 5521 (APR 2024), Record of Emergency Data and Designation of Beneficiary for Unpaid Compensation of Deceased NAF Employee, Department of the Army (the Official source link on this page).