Dd Form 397 – Fill Out and Use This PDF

CLAIM CERTIFICATION AND VOUCHER FOR	1. BUREAU VOUCHER NO.	2. D.O. VOUCHER NO.	OMB No. 0730-0017
DEATH GRATUITY PAYMENT			OMB approval expires
(10 U.S.C. 1475-1480 and regulations pursuant thereto)			OCT 31, 2011

Return completed form to the appropriate Service Casualty Office or contact the Service Pay or Finance Office for direction on where to submit your completed form. DO NOT return your form to the address in the paragraph below.

The public reporting burden for this collection of information is estimated to average 30 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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 (0730-0017). 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.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Sections 1475-1480, and E.O. 9397.

PRINCIPAL PURPOSE(S): To record the name and address of the designated beneficiary(ies) or next-of-kin eligible to receive the death gratuity payment for the deceased service member, in accordance with a finding by the Secretary of the Service concerned, and to maintain a record of the disbursement of these benefits.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information

contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD "Blanket Routine Uses" set forth at the beginning of DoD's compilation of systems of records notices apply to this system.

DISCLOSURE: Disclosure is voluntary; however, failure to provide the requested information may impede or delay the processing of this claim.

NOTE: Penalties for presenting false claims or making false statements in connection with claims may include criminal fines or imprisonment of up to 5 years per incident and civil fines in excess of $10,000 (False Claims Act, as amended, 31 U.S.C. Sections 3729-3733 and 18 U.S.C. Sections 287 and 1001).

3.	APPROPRIATION SYMBOL AND TITLE				4. PAID BY
5.	NAME AND ADDRESS OF PAYEE (Number and Street, City, State and ZIP Code)
6. SERVICE MEMBER (Last name - First name - Middle initial)				7. SOCIAL SECURITY	NO.	8. GRADE
9. PLACE OF DEATH				10. DATE OF DEATH		11. DUE PAYEE
12. CERTIFICATE OF PAYEE (Place an "X" in one of the following boxes, according to your				relationship to the decedent)
	I certify that I have not received gratuity pay; that I am:
	a.	HIS WIDOW	HER WIDOWER. (Complete only Block 14a and have Block 14 signed by two certifying witnesses.)

b. A CHILD OF THE DECEDENT; THAT THERE IS NO WIDOW(ER) SURVIVING; THAT THE CONTENTS OF BLOCK 13 ARE ACCURATE AS SHOWN. (If payee is a minor at time of preparation of this form, Block 14a must be completed by the duly appointed guardian and documentary proof of guardianship furnished. Complete Blocks 13 and 14a and have Block 14 signed by two certifying witnesses.)

c. THE

FATHER

MOTHER

BROTHER

SISTER OF THE DECEDENT;

THAT THERE IS NO WIDOW(ER), OR CHILD SURVIVING. (Complete Blocks 13 and 14a and have Block 14 signed by two certifying witnesses.)

d. OTHER

13. CHILDREN OF THE DECEDENT (If none, so state. Attach additional page if more space is needed)

a. NAME (Last, First, Middle Initial)

b. ADDRESS (Include ZIP Code)

14. CERTIFICATE OF WITNESSES TO SIGNATURE OF PAYEE (Two witnesses are required)

a. SIGNATURE OF PAYEE (Must be affixed

I certify that I am personally well acquainted with the above-named payee, that I have read the

in the presence of two witnesses)

above statement which was signed in my presence, and that said statement is true to the best of my

knowledge and belief.

b. FIRST WITNESS

c. SECOND WITNESS

d. ADDRESS OF PAYEE (Include ZIP Code)

(1) SIGNATURE

(1) SIGNATURE

(2) ADDRESS (Include ZIP Code)

(2) ADDRESS (Include ZIP Code)

15. ADMINISTRATIVE STATEMENT

The above-named payee is authorized to receive gratuity pay due to the death of the decedent; and has been so designated by the decedent.

a. TYPED NAME	b. TITLE	c. SIGNATURE	d. DATE (YYYYMMDD)

16. PAYMENT

a. PAID BY CHECK DRAWN IN FAVOR OF PAYEE NAMED ABOVE			b. ELECTRONIC FUNDS TRANSFER (EFT)
(1) CHECK NUMBER	(2) AMOUNT OF CHECK	(3) DATE OF CHECK	(1) BANKING INSTITUTION	(2) ACCOUNT NUMBER	(3) ROUTING NUMBER

DD FORM 397, DEC 2008

PREVIOUS EDITION IS OBSOLETE.

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