Form Information
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FORM NUMBER:
DD2877

TITLE:
TRICARE PRIME DISENROLLMENT APPLICATION

EDITION DATE:
20110201

CANCELLATION DATE:
20130103

FORMATS:
PLEASE BE ADVISED:

No link under "FORMATS:" indicates no electronic format is available.

To obtain copies of forms, contact YOUR Military Service or Component

Forms Manager click here.

Cancelled forms are not available.

REMARKS:
This form is no longer needed and can be cancelled. "Disenrollment" was

incorporated into the new DD Form 2876, TRICARE Prime Enrollment,

Disenrollment and PCM Change Form.

ISSUANCES:

SPONSOR / POC:
HA

SUB-SPONSOR:

NUMBER OF PAGES:
4

USERS*:
A N AF

PRESCRIBED OR ADOPTED?:
P

DISPOSITION:
O

SUBJECT GROUP:
6010

FORM CONTROLLED:
N

MANDATORY PRINT SPECIFICATIONS:
N

RCS:

IRCN:

OMB:
0702-0008

PRIVACY ACT IMPLICATIONS:
Y
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* All revisions and/or cancellations must be coordinated through these USERS.

DISPOSITION: O = Do NOT use previous edition. U = Use previous edition until supply is depleted.