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: 5 U.S.C. Section 301; 10 U.S.C. chapter 147; 10 U.S.C. Sections 1061 - 1065, 1072 - 1074, 1074a - 1074c,
1074c(1), 1076, 1076a, 1077, 1095(k)(2); 50 U.S.C. chapter 23; E.O. 9397; E.O. 10450, 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://privacy.defense.gov/notices/osd/DMDC02.shtml
.
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), APR 2012
The instructions for completing the DD Form 1172-2 should be closely followed to ensure accurate data collection and to
preclude overcollection 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 10 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, 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.
