Dd Form 2065 PDF Details

Dd form 2065, also known as the "Report of Medical Examination" is a document used in the military to report a person's medical history. This document is used to determine if someone is physically able to serve in the military, and can be used as evidence in the event that the individual need medical care or benefits from the Veterans Affairs office. The form is filled out by a qualified medical professional, usually a doctor, and must be completed in full for it to be valid. The information on dd form 2065 can also be used to establish Service connection for disabilities incurred during active duty service. For more information on Dd Form 2065 or other veteran's benefits, please contact your local Veterans Affairs office.

QuestionAnswer
Form NameDd Form 2065
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSSN, REIMBURSABLE, irs form 2065, OCT

Form Preview Example

DISPOSITION OF REMAINS - REIMBURSABLE BASIS

OMB No. 0704-0030 OMB approval expires May 31, 2006

The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0030). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE ADDRESS IN ITEM 1.

PRIVACY ACT STATEMENT

AUTHORITY: 10 USC Sections 1481 through 1488; EO 9397.

PRINCIPAL PURPOSE: To record the sponsor's disposition instructions for the remains. To record cost for necessary services and supplies. To record the name, address and telephone number of a person in CONUS who may be contacted concerning the remains, if necessary. ROUTINE USES: None.

DISCLOSURE: Voluntary; however, failure to furnish the requested information may delay processing and shipment of remains to final destination.

1.

TO: (Recipients and address authorized distribution)

2.

NAME OF DECEASED (Last, First, Middle Initial)

 

 

 

 

 

 

3.

RELATIONSHIP TO SPONSOR

 

 

 

 

4.

NAME OF SPONSOR (Individual, Agency or Firm)

5.

ADDRESS OF SPONSOR (Street, City, State and ZIP Code)

6. GRADE OF SPONSOR

7. SSN OF SPONSOR

I, THE UNDERSIGNED, DESIRE THAT DISPOSITION OF REMAINS BE EFFECTED AS INDICATED BELOW: (X applicable option)

8.OPTION 1

a. Preparation of remains at the Government mortuary and return of remains to a continental United States port of entry in a transfer case.

The port mortuary will furnish the requested services and supplies at a cost of $

. I have reimbursed the Government

 

 

 

in this amount. It is requested that the remains be shipped to the following funeral home:

 

b. NAME OF FUNERAL HOME

c.ADDRESS OF FUNERAL HOME (Street, City, State and ZIP Code)

9.OPTION 2

a. Preparation of remains at the Government mortuary and return of remains to a continental United States port of entry in a transfer case. The port mortuary officer is requested to release the remains to the following funeral home:

b. NAME OF FUNERAL HOME

c.ADDRESS OF FUNERAL HOME (Street, City, State and ZIP Code)

10.OPTION 3 - ARRANGEMENTS DESIRED (Other than those described in Options 1 or 2)

11. RELATIVE OF DECEASED (or other person) IN CONUS WHO MAY BE CONTACTED, IF NECESSARY

a. NAME (Last, First, Middle Initial)

b. ADDRESS (Street, City, State and ZIP Code)

c. RELATIONSHIP

d.TELEPHONE (Include Area Code)

e. DATE SIGNED

f. SIGNATURE OF SPONSOR

DD FORM 2065, OCT 2003

PREVIOUS EDITION IS OBSOLETE.

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How you can prepare da 2065 stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - RELATIVE OF DECEASED or other, b ADDRESS Street City State and, c RELATIONSHIP, d TELEPHONE Include Area Code, e DATE SIGNED, f SIGNATURE OF SPONSOR, DD FORM OCT, and PREVIOUS EDITION IS OBSOLETE with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

The best ways to prepare da 2065 step 2

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