Attachment_4-_Application_for_Identification_Card-Deers_Enrollment_(DD1172-2).pdf

PDF 57 KB Posted Dec 8, 2017

Attached to: Special Needs Coordinator Federal contract opportunity
Solicitation number: FA520518QMG01
Issued by: Department of the Air Force Pacific Air Forces

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Application for Identification Card-Deers Enrollment (DD1172-2)

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DD Form 1172-2, Application for Identification Card/DEERS Enrollment, January 2014

WHS/ESD/DD

9.0.0.2.20120627.2.874785

SECTION VI - RECEIPT

SECTION V - DEPENDENT INFORMATION (Attach additional pages if necessary)

SECTION III - AUTHORIZED BY

SECTION IV - VERIFIED BY

SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS

SECTION I - SPONSOR/EMPLOYEE INFORMATION

APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT

Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.

OMB No. 0704-0415 OMB approval expires March 31, 2020

1. NAME (Last, First, Middle)

2. GENDER

3. SSN OR DOD ID NO.

4. STATUS

5. ORGANIZATION

6. PAY GRADE

11. CURRENT HOME ADDRESS

12. CITY

13. STATE

14. ZIP CODE

15. COUNTRY

16. PRIMARY E-MAIL ADDRESS

51. TELEPHONE NUMBER

(Include Area Code/DSN) Permission to use for benefits notifications (18 and above)

50. PRIMARY E-MAIL

ADDRESS

Permission to use for benefits notifications (18 and above)

64. PRIMARY E-MAIL

ADDRESS

65. TELEPHONE NUMBER

(Include Area Code/DSN) Permission to use for benefits notifications

9. DATE OF BIRTH

(YYYYMMMDD)

10. PLACE OF BIRTH

18. CITY OF DUTY LOCATION

19. STATE OF DUTY

LOCATION

20. COUNTRY OF DUTY

LOCATION

30. OVERSEAS ASSIGNMENT BEGIN

DATE (YYYYMMMDD)

31. OVERSEAS ASSIGNMENT END

DATE (YYYYMMMDD)

24. SPONSORING OFFICE NAME

26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)

25. CONTRACT NUMBER

32. ELIGIBILITY EFFECTIVE DATE

(YYYYMMMDD)

33. ELIGIBILITY EXPIRATION DATE

(YYYYMMMDD)

21. REMARKS (Cite legal documentation, as applicable.)

NOTARY SIGNATURE

AND SEAL

I certify the information provided in connection with the eligibility requirements of this form is true and accurate to the best of my knowledge.

(If not signed in the presence of the authorizing/verifying official, the signature must be notarized.)

22. SPONSOR/EMPLOYEE SIGNATURE

23. DATE SIGNED (YYYYMMMDD)

34. SPONSORING OFFICIAL NAME (Last, First, Middle)

36. TITLE

40. VERIFYING OFFICIAL NAME (Last, First, Middle Initial)

41. SITE IDENTIFICATION

43. SIGNATURE

37. PAY

GRADE

38. SIGNATURE

72. SIGNATURE

73. DATE ISSUED (YYYYMMMDD)

DD FORM 1172-2, MAR 2017

This form valid for issue of DoD ID Card for 90 days from date of verification.

29. OVERSEAS ASSIGNMENT

(Country)

8. CITIZENSHIP

27. SPONSORING OFFICE

TELEPHONE NUMBER

(Include Area Code/DSN)

42. TELEPHONE NUMBER

(Include Area Code/DSN) I certify the individual identified above, based on personal knowledge and available documentation, is in a status eligible for and requires an identification card in the performance of their duties with the DoD or Uniformed Services.

35. UNIT/ORGANIZATION NAME

39. DATE VERIFIED

(YYYYMMMDD)

44. NAME (Last, First, Middle)

71. ELIGIBILITY EXPIRATION

DATE (YYYYMMMDD)

70. ELIGIBILITY EFFECTIVE

DATE (YYYYMMMDD)

69. COUNTRY

68. ZIP CODE

67. STATE

66. CITY

63. CURRENT HOME ADDRESS

62. SSN OR DOD ID NO.

61. RELATIONSHIP

60. DATE OF BIRTH

(YYYYMMMDD)

59. GENDER

58. NAME (Last, First, Middle)

45. GENDER

47. RELATIONSHIP

48. SSN OR DOD ID NO.

49. CURRENT HOME ADDRESS

52. CITY

53. STATE

54. ZIP CODE

55. COUNTRY

Receipt of new card is acknowledged.

7. GEN. CAT

56. ELIGIBILITY EFFECTIVE

DATE (YYYYMMMDD)

57. ELIGIBILITY EXPIRATION

DATE (YYYYMMMDD)

A B

17. TELEPHONE NUMBER

(Include Area Code/DSN)

28. OFFICE EMAIL ADDRESS

46. DATE OF BIRTH

(YYYYMMMDD)

PREVIOUS EDITION IS OBSOLETE.

Adobe Designer 9.0

INSTRUCTIONS

PRIVACY ACT STATEMENT

AGENCY DISCLOSURE NOTICE

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.

RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL IDENTIFICATION SYSTEM WORK STATION.

AUTHORITY: 10 U.S.C. Chapter 53, Miscellaneous Rights and Benefits; 10 U.S.C. Chapter 54, Commissary and Exchange Benefits; 50 U.S.C. Chapter 23, Internal Security; DoD Instruction 1341.2, Defense Enrollment Eligibility Reporting System (DEERS) Procedures; Homeland Security Presidential Directive 12, Policy for a Common Identification Standard for Federal Employees and Contractors; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To apply for and enroll in the Defense Enrollment Eligibility Reporting System (DEERS) for DoD benefits and privileges. These benefits and privileges include, but are not limited to, medical coverage, DoD Identification Cards, access to DoD installations, buildings or facilities, and access to DoD computer systems and networks.

ROUTINE USE(S): To Federal and State agencies and private entities; individual providers of care, and others, on matters relating to claim adjudication, program abuse, utilization review; professional quality assurance; medical peer review, program integrity, third party liability, coordination of benefits and civil and criminal litigation, and access to Federal government and contractor facilities, computer systems, networks, and controlled areas. The DD Form 1172-2 currently covers the RUs that would include retirees and dependents. To the Department of Health and Human Services, the Department of Veterans Affairs, the Social Security Administration, and to other Federal, state, and local government agencies to identify individuals having benefit eligibility in another plan or program. For a complete list of DEERS routine uses, visit: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-dod/

Applicant information is subject to computer matching within the Department of Defense or with other Federal or non-Federal agencies. Matching programs are conducted to assure that an individual eligible under a Federal program is not improperly receiving duplicate benefits from another program. A beneficiary or former beneficiary who has applied for privileges of a Federal Benefit Program and has received concurrent assistance under another plan will be subject to adjustment or recovery of any improper payments made or delinquent debts owed.

DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a Uniformed Services Identification Card and/or non-enrollment in the Defense Enrollment Eligibility Reporting System, refusal to grant access to DoD installations, buildings, facilities, computer systems and networks.

Penalty for presenting false claims or making false statements in connection with claims: fine of up to $10,000 or imprisonment for up to five years or both.

DD FORM 1172-2 (BACK), MAR 2017

The instructions for completing the DD Form 1172-2 should be closely followed to ensure accurate data collection and to preclude over collection of information. Section IV of this form should only be completed if benefits or sponsorship is being requested for/by an eligible sponsor or their dependent. Instructions for the DD Form 1172-2 can be found at: http://www.cac.mil/docs/1172-2-Instructions.pdf.

The public reporting burden for this collection of information is estimated to average 3 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, Directives Division, Information Management Branch, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0415). 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.

51. Telephone number (include area code/DSN).:

50. Primary e-mail address.:

X if granting permission to use email address for benefits notifications.: 0

65. Telephone number (include area code/DSN).:

64. Primary e-mail address.:

X if granting permission to use email address for benefits notifications.: 0

Section 1 - Employee identification. Employee name (last, first, middle initial).:

2. Gender:

3. Social security number or other DoD identification number.:

4. Status.: Contractor

5. Organization.: 35 MDG

6. Pay grade.: BLANK

7. General category.: BLANK

8. Citizenship.:

9. Date of birth (enter as four digit year, three letter month, two digit day).:

10. Place of birth.:

11. Home street address.: PSC

Enter additional address information if needed.:

12. City.: APO

13. State.: AP

14. Zip code.: 96319

15. Country.: US

16. Primary e-mail address.:

17. Telephone number (include area code/DSN).:

18. City of duty location.: Misawa

19. State of duty location.:

20. Country of duty location.: Japan

Section 2 - Employee Certification and Remarks. 21. Remarks (cite legal documentation as applicable). Space at right is for notary signature and seal, if applicable.:

23. Date signed. (4 digit year, 3 letter month, 2 digit day).:

Section III - Authorized by. 24. Sponsoring office name.:

25. Contract number.:

26. Sponsoring office address (street, city, state and zip code).:

28. Office email address.:

29. Country of overseas assignment.:

30. Beginning date of overseas assignment (4 digit year, 3 letter month, 2 digit day):

31. Ending date of overseas assignment. 4 digit year, 3 letter month, 2 digit day.:

32. Effective date of eligibility status. 4 digit year, 3 letter month, 2 digit day.:

27. Sponsoring office telephone number (include area code/DSN).:

33. Eligibility expiration date. 4 digit year, 3 letter month, 2 digit day.:

34. Sponsoring official name (last, first, middle initial).:

35. Unit or organization name.:

36. Title.:

37. Pay grade.:

39. Date verified (4 digit year, 3 letter month, 2 digit day).:

Section V - Dependent Information. A. First dependent. 44. Name, last, first, middle.:

45. Gender.:

46. Date of birth (enter as four digit year, three letter month, two digit day).:

47. Relationship.:

48. Social security or other DoD identification number.:

49. Current home street address.:

Enter additional address information if needed.:

52. City.:

53. State.:

54. Zip code.:

68. Zip code.:

55. Country.:

56. Eligibility effective date: 4 digit year, 3 letter month, 2 digit day.:

57. Eligibility expiration date (4 digit year, 3 letter month, 2 digit day).:

B. Second dependent. 58. Name, last, first, middle.:

59. Gender.:

60. Date of birth (enter as four digit year, three letter month, two digit day).:

61. Relationship:

62. Social security or other DoD identification number.:

63. Current home street address.:

Enter additional address information if needed.:

66. City.:

67. State.:

69. Country.:

70. Eligibility effective date: 4 digit year, 3 letter month, 2 digit day.:

71. Eligibility expiration date (4 digit year, 3 letter month, 2 digit day).:

73. Date issued (4 digit year, 3 letter month, 2 digit day).:

X if granting permission to use email address for benefits notifications.: 0

40. Verifying official name (last, first, middle initial).:

41. Verifying official site identification.:

42. Verifying official telephone number (include area code/DSN).:

72. Signature.:

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