Da Form 3715 – Fill Out and Use This PDF

US ARMY NONAPPROPRIATED FUNDS - DISPOSITION OF RETIREMENT BENEFITS

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

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

National Defense Authorization Act for Fiscal Year 1996; 26 U.S.C. 401, Qualified Pension, Profit-sharing, and Stock Bonus Plans;

Army Regulation 215-3, Nonappropriated Funds Personnel Policy; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE: The information you provide is for the purpose of preparing a refund of contribution or to process a retirement annuity.

ROUTINE USES:

This information is used to prepare a refund or deferred annuity as requested from terminating employees; process a monthly

annuity payment for retiring employees, and to process survivor benefits. In addition to those disclosures generally permitted

under 5 USC 552a (b) (Privacy Act), the information contained therein may specifically be disclosed outside the Department

of Defense as routine pursuant to 5 U.S.C. 552a (b) 3 as follows: Information may be disclosed to appropriate federal

agencies, such as Department of Labor and the Equal Employment Opportunity Commission, to resolve and/or adjudicate

matters falling within their jurisdiction. Records may also be disclosed to labor organizations in response to requests for

DISCLOSURE:

names of employees and identifying information.

Voluntary. However, failure to provide the information within one year of termination of employment will result in automatic

refund of contributions and denial of annuity.

CITATION:

A0215-3 SAMR, NAF Personnel Records (June 1, 2000, 65 FR 35054).

SECTION I - GENERAL INFORMATION

1. EMPLOYEE'S NAME (Last, first, MI)

2. SOCIAL SECURITY NUMBER

3. DATE OF BIRTH (YYYYMMDD)

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

12. NAME OF LEGAL SPOUSE (Last, First, MI)

NOT MARRIED

MARRIED

13. SOCIAL SECURITY NUMBER OF LEGAL SPOUSE

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

(

)

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 Disability Retirement due to work related injury.

(

)

I request Survivor Benefits.

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

b. DATE (YYYYMMDD)

c. MAILING ADDRESS

d. E-MAIL ADDRESS

DO NOT USE - FOR OFFICIAL USE ONLY

20.

DATE RECEIVED (YYYYMMDD)

21. DATE PROCESSED (YYYYMMDD)

22. PROCESSED BY

DA FORM 3715, AUG 2019

PREVIOUS EDITIONS ARE OBSOLETE.

APD LC v1.00ES