DA Form 7574 Request and Certification for Incapacitation Pay

How to Fill Out DA Form 7574?

An overview of the form and filing guidelines can be found in the Department of the Army Pamphlet 135-381, Incapacitation of Reserve Component Soldiers Processing Procedures. DA Form 7574 instructions are as follows:

1. Section I ("Claim Statement") must contain accurate personal data required for identification purposes: the name of the soldier, their rank, SSN, unit of assignment, etc. The soldier is obliged to disclose nonmilitary earned income. It includes income from self-employment along with regular wages, nonmilitary employment, tips, professional fees, salaries, or any other compensations for personal services. It is necessary to indicate whether the service member had been receiving VA Disability Compensation or Supplemental Income from an Income Protection Plan at the time of sustaining the injury or illness and provide the exact days of incapacitation. The soldier must sign the section to certify that all statements are true. Providing false or incomplete information and the nondisclosure of outside income may result in a fine or imprisonment.
2. Section II ("Employer's Verification") should be filled in by the soldier's employer. It verifies the information on the applicants' employment, benefits, and the amount of income lost.
3. Section III ("Commander's Verification") is filled in by the soldier's commander and verifies all of the information provided in Section I.
4. Section IV ("Review/Approval") is completed by higher headquarters or approving authority.

The completed DA 7574 and all paperwork related to the claim should be submitted through the chain of command.

The soldier is strongly encouraged to file an incapacitation pay claim in case of a service-related injury, disease, or illness that prevents them from performing military duties or has resulted in a loss in non-military income. In order to receive incapacitation pay, a correctly filled-in DA 7574 should be completed and submitted for each calendar month claimed.

Publications related to DA Form 7574:

• DA Form 7574-1, Military Physician's Statement of Soldier's Incapacitation/Fitness For Duty, is a form used by the physician to confirm the soldier's eligibility for performing military duties;
• DA Form 7574-2, Soldier's Acknowledgement of Incapacitation Pay Counselling, is filed by the soldier to document that they have received the proper counseling regarding incapacitation pay.