VA Form 27-0820c Report of Defense Finance and Accounting Service (DFAS)

OMB Control No. 2900-0734
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

REPORT OF DEFENSE FINANCE & ACCOUNTING SERVICE (DFAS)
NOTE - This form must be filled out in ink or on a computer, as it
becomes a permanent record in the veteran's folder.

1. VA OFFICE

2. IDENTIFICATION NUMBERS (C, XC, SS, XSS, V, K, etc.)

3. LAST NAME - FIRST NAME - MIDDLE NAME OF VETERAN (Type or print)

4. DATE OF CONTACT (Month, day, year)

5. ADDRESS OF VETERAN (Include number and street or rural route, city or P.O., State and ZIP Code)

6A. TELEPHONE NUMBER OF VETERAN (Include Area Code)
DAY

EVENING

6B. E-MAIL ADDRESS (If applicable)
7. NAME OF PERSON CONTACTED

8. TYPE OF CONTACT

9. ADDRESS OF PERSON CONTACTED

PERSONAL
TELEPHONE
10. TELEPHONE NUMBER OF PERSON CONTACTED

(Include Area Code)

11. BRIEF STATEMENT OF INFORMATION REQUESTED AND GIVEN (If needed, continue on a separate sheet)
The following is information received from DFAS regarding the above-named veteran's military retired pay or survivor's SBP and will be used to offset any
compensation award as provided by 38 CFR 3.750 and M21-1MR, Part III, Subpart V, Chapter 5 or DIC as provided by 10 U.S.C. § 1450 (c) (1) and
M21-1, Part IV, Subpart iii, Chapter 3, Section F.
The veteran's record was properly identified by confirming the following information (check all that apply)
FULL NAME

DATE OF DEATH

PAY GRADE

SOCIAL SECURITY NUMBER

BRANCH OF SERVICE

DATE OF BIRTH

DATES OF SERVICE

12. SUMMARY OF INFORMATION RECEIVED:
In receipt?

YES

NO

PERMANENT

TDRL

SBP

13. RETIRED PAY/SBP/SEPARATION OR SEVERANCE PAY
A. Verified retired pay amount(s):

B. Verified SBP:

DATE

GROSS PAY

DATE

DATE

GROSS PAY

AMOUNT

DATE

GROSS PAY

SBP OVERPAYMENT

C. Verified Separation/Severance Pay
SEPARATION
SEVERANCE
DATE

NAME OF SBP RECIPIENT
DATE

GROSS PAY

DATE

GROSS PAY

GROSS
NET

SSN OF SBP RECIPIENT

A copy of this form was sent to Power of Attorney of record (If applicable)
cc:
DIVISION OR SECTION

EXECUTED BY (Signature and title)

PRIVACY ACT NOTICE: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 5, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education and Veteran Readiness and Employment Records - VA, published in the Federal
Register. Your obligation to respond is required to obtain or retain benefits. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
RESPONDENT BURDEN: An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control
Number. The OMB control number for this project is 2900-0734, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 minutes per
respondent, per year, 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 and any other aspect of this collection of information, including suggestions for reducing the burden to VA Reports Clearance
Officer at VACOPaperworkReduAct@VA.gov. Please refer to OMB Control No. 2900-0734 in any correspondence. Do not send your completed VA Form 27-0820c to this email address.
VA FORM
XXX XXXX

27-0820c

SUPERSEDES VA FORM 27-0820c, DEC 2021,
WHICH WILL NOT BE USED.