Directorate of Public Works (DPW)
Housing Division
Signature: ________________________________
Date: _____________________________
*Unaccompanied with Military Spouse in Korea )
*Unaccompanied receiving BAH at With Dependent rate )
Duty Phone #:
Cell Phone #:
Departed Last
Duty Station:
Date arrived
in Korea:
Government Email:
Personal Email:
Joint move-in insp. :
Name (Last, First, MI):
Service Branch:
( )
(ensure DOD ID is correct and legible)
Air Force
Coast Guard
Rank (Grade):
Date of Rank:
Unit & UIC:
Marital Status:
Male )
Female )
Single )
Married )
Widowed ) Divorced )
Unaccompanied ) Accompanied ) Joint Domicile )
Current as of 9 NOV 20 (CHI)
Installation/Organization Transfered from:
On orders to relocate from another area in Korea? ( )Yes ( )No
If yes, Date of Final Termination From Quarters in Area I,II,IV, or V
________________________ (<----This will also be your move in
date to Humphreys and key issue date)
(Please print legibly)
Date of Birth: __________________
ETS Date: _____________________
Date to be Released from Quarantine: ________________________
click to sign
click to edit
3-Liability for Damage to Assigned Housing
4-Pin-point Orders
5-PCS Orders
6-DA31 (or Installation Clearing Papers)
7-ERB/ORB/DA 4187 etc. (if needed)
Before Turning In Your Packet:
Check all forms to ensure they are
filled out completely.
Make sure you have:
-signed/dated Liability for Damage to Assigned Housing
Current as of 9 NOV 20 (CHI)
Required Documents for Virtual In-processing
*Housing Office will provide SLQ BLDG / RM to SM depending on availability.
Housing Office will set the SLQ Joint move-in inspection schedule at the earliest possible time. SM must
be present at SLQ room on the day of SM's joint move-in inspection.
The Joint move-in inspection will be scheduled on the next duty day following quarantine release. Due
to Holiday / Weekend or non-availability of inspection schedules, SM may be asked to stay at the on-
post army lodging more than 1-day. This lodging cost will be covered under in-bound TLA
(Temporary Lodging Allowance).
*SM is not authorized TLA after joint move-in inspection.
*SM should check out of lodging by 1100 to prevent a late check-out fee on the day of joint move-in
SM has to turn in 'Zero Balance' Lodging Receipt, Housing TLA memo and USFK Form 122 to the Finance
Office for reimbursement.
*For Additional assistance, please contact your unit sponsor.
I, ________________________________________ assigned to______________/____________ , on ___________________
(Servicemember's Rank & Full Name) building / room number
(joint move-in inspection)
Please initial on the left of each item to verify that you have been briefed and understand each statement.
_______1. Assignment to SLQ: I am being assigned to on-post Senior Leader Quarters (SLQ) and I understand, per Garrison Policy 36, that once I am
assigned a room and accept a key, the assignment is permanent and relocation will not be authorized except in the case of health or safety and/or directed by the
Garrison Commander. I further understand that I must take a room assignment no later than the last day of my in-processing with 19th HRC. If I am staying in
lodging/hotel I will be assigned a room today, but I will need to check out of the lodge/hotel before 1100hrs tomorrow morning (next duty day) and return to
housing to receive a room key.
I am a (initial one and N/A the other):
______ Bona Fide Bachelor
: I am being assigned to SLQ due to the occupancy rate being below 95%, or the occupancy rate is over 95%
I am electing to live in SLQ anyway.
______ Geographical Bachelor, I am being assigned to SLQ due to the occupancy rate being below 100%.
Resident Use: I will use the premises solely as an unaccompanied single residence for myself. I understand use of the unit
purpose, including the shelter of any additional number of persons except temporary guests, to include family members, is prohibited without prior written
consent of the housing manager.
_______3. Visitation Request: I must request visitation authorization from the Housing Office PRIOR to having long term visitors in government quarters.
Visitation Authorization Requests Forms are available to service members upon request in the Housing Office.
_______4. Stoppage of BAH for Dependents Visit more than 90days: IAW JTR Chapter10, Part E, Section 3. - Dependents may visit the OCONUS PDS
without changes to allowances. However, I understand that if the visit exceeds 90 consecutive days, it is no longer a visit but a change of the dependents’
permanent residence and I must change my OHA to w/Dependent Rate & forfeit BAH allowance. I acknowledge and understand I cannot receive multiple
housing allowances for dependents.
_______5. Condition of Property: I will conduct a Joint Move-in Inspection with Housing Inspector on the day of SLQ move-in.
_______6. Government Furniture Removal: If you have government issued furniture you want removed in order to use personal HHG furniture, you will need
to call Furniture Management Branch within 1st 90 days, for a one time pick up only. Any additional Government pick up request will be at the SM’s expense to
return to FMB.
_______7. Furniture and Appliances Repair: DSN:4357 (HELP) From Cell: 0503-356-HELP (4357) Choose option #4.
_______8. General Maintenance, Neglect, Willful Damage and Costs: I understand that I will, at my own expense: (a) replace or repair all broken or
damaged glass, screens, flooring, wood, plaster, drywall, and locks, occurring during my occupancy, normal wear and tear excepted; (b) keep in a state of good
repair and cleanliness, all parts of the property, including equipment and appliances, and keep all property free from objectionable features, nuisances,
and hazards.
Any repairs or replacement of property, equipment, or appliances required due to the abuse or negligence by acts of commission or omission
of resident or guest(s) will be paid for by the me. At the termination of occupancy, all appliances and equipment should be in good working order and the
premises should be in a clean condition, normal wear and tear excepted. Approval of the housing manager must be obtained before I place any
exceptionally heavy articles in the unit which may damage the unit's structural integrity.
________9. Notice of Defects or Malfunctions: I will promptly notify the Housing Maintenance contractor DSN: HELP(4357) or Cell
0503-356-HELP(4357) when the structure or the equipment of any fixture contained therein becomes defective, broken, damaged, or malfunctions
in any way.
________10. Redecorating and Alterations: I understand I must obtain written permission before redecorating and must not make any
alterations, additions, or improvements without first obtaining written consent. Such alterations could, at the option of the housing manager, remain with
the property or be removed by the resident. When removing such alterations, the house and premises must be returned to its original condition at my own expense.
_______11. Access to Property by the Housing Manager and His/Her Duly Designated Representatives: When warranted by circumstances or reasonable
cause, the installation commander or a duly designated representative may enter the premises to conduct a visual inspection. The resident must be
given advance written notice of the purpose and objective of the inspection.
_______12. System Overloads: I will not install or use any equipment that will overload any gas, water, heating, electrical, sewage, drainage, or air
conditioning systems of the assigned premises.
You have been asked to provide information or documents containing personal information that will be retained in your customer file here in the
Housing Office. The authority of the Government to request and retain this information, the purpose for which it is requested, and the possible routine
uses are outlined below. You are entitled to a copy of this Privacy Act statement. Authority: 10 USC 3013, Secretary of the Army, EO 9397 (SSN).
Principal Purposes: To provide housing and related services for military personnel, their dependents, and qualified civilian employees; to render
reports; to investigate complaints; and to provide information necessary to prepare the lease-rental contract for housing in the community.
Routine Uses: In addition to those disclosures generally permitted under 5 USC 552a(b) of the Privacy Act, these records or information contained
therein may specifically be disclosed outside the DOD as a route use pursuant to 5 USC 552a(b)(3) as provided in any of the Blanket Routine Uses set
forth at the
beginning of the Army’s compilation of systems of records notices.
Disclosure: Voluntary. However, if the information is not provided, the individual will not be considered for a lease rental contract or issuance and use
of Government-owned furnishings.
____________________________/_________________ ________________________________/________________
Service Member Signature and Date Housing Representative Signature and Date
_______13. Smoke Detectors: I am responsible for checking smoke detectors periodically during occupancy and keeping them in proper working
condition and to report any malfunctions to the Fire Department, 753-6173.
_______14. Resident Conduct: Residents should conduct themselves and require other persons on the premises to conduct themselves in a manner that will
not disturb their neighbors. I acknowledge that noise complaints from my neighbors will cause the issue to be elevated to my Chain of Command for
resolution. Multiple complaints of noise from guest(s), to include family members, will cause me to lose my visitation privileges.
_______15. Insurance: Because of potential liability claims for damages, loss to the assignee housing units, the resident is encouraged to obtain private
liability insurance which provides protection of his/her personal property and the unit to which he/she is assigned.
_______16. Health and Safety: I will comply with all health and safety regulations imposed by the local Garrison.
_______17. Tour Extension/AIP: I understand that I must provide the Housing Office any approved tour extension, so that my DEROS can be changed in
my file.
_______18. Pets: At no time are pets allowed in UPH SLQ. No exceptions to policy (ETP) will be granted for pets. In order for a SM on unaccompanied
orders to get an approved ETP for a pet, the pet will first have to be classified as a service animal per Army Directive DODI 1300.25 and Army Directive
2013-01. The request would then have to be validated by the Deputy Chief Behavioral Health, 65th Medical Brigade, and concurred by the Deputy
Commander for Clinical Services, 65th Medical Brigade, before submission to housing for approval.
______19. Single Pregnant Service Member on UPH Orders: Single pregnant service members can move off post and collect w/out dependent rate OHA
at 28 weeks (i.e. 12 weeks from the due date). Service member must present proper medical documentation (i.e., pregnancy profile) and, 1SG /Company
Commander’s approval prior to moving off post. Once the child is born it is the single service member’s responsibility to provide the birth certificate to the
Housing Office to change OHA rate from the “without” dependent rate, to the “with” dependent rate OHA. No Certificate of Non Availability (CNA) is
NOTE: This applies if you are a bona fide single service member collecting ‘NO” OHA/BAH entitlements. If single and currently collecting dependent rate
OHA/or BAH, see below, "Married Pregnant Service Member on UPH Orders."
______20. Married Pregnant Service Member on UPH Orders: Married pregnant service members are able to move off post at their own expense. No
Certificate of Non Availability (CNA) is authorized. If service member has dependents residing elsewhere collecting “with” dependent rate OHA/or BAH, and
once child is born (additional dependent), the soldier must decide where she wants to continue to collect “with” dependent rate OHA or BAH as the service
member is only AUTHORIZED ONE entitlement. NOTE: IAW JFTR Ch 10: Housing Allowances Part E: Assignment Situations/Section 2: Mbr with Dep
(U10402E-2) 7. Multiple Dependent Locations: In instances of multiple dependent locations, the member must designate the dependents' primary residence.
The housing allowance rate is based on this primary residence.
______21. Out-Processing: 60 days PRIOR to PCS time I will notify the Housing Office. Housing will schedule a pre/termination inspection according to
your flight schedule. You do NOT need orders to schedule pre/term inspection however the day of term inspection PCS orders are mandatory to clear and out-
______22. Occupant Handbook: I received a copy of the Occupant Handbook for Unaccompanied Housing, with mold information.
Information Required by the Privacy Act of 1974
Current as of 9 NOV 20 (CHI)
click to sign
click to edit
click to sign
click to edit
Liability for Damage to Assigned Housing
1. Public law makes military residents of Government housing units legally responsible for damage
to the units, or for damage or loss of Government-issued appliances and furniture. This notice
explains the rules which apply to family and permanent party unaccompanied personnel housing.
You should read it carefully and keep a copy for your records.
a. First, you can be held pec uniarily liable when your Government housing, appliances, or
furnishings are lost, damaged, or destroyed as a result of your negligence or abuse. You are
negligent if you act carelessly, or if you are aware that your family members, or those you allow on
the premises, are likely to act carelessly and do not take proper steps to prevent or minimize such
conduct. Abuse means either willful misconduct or the deliberate unauthorized use of housing, that
is, conducting an unautho rized business in the housing unit.
b. Second, the Army has limited your liability to an amount equal to one month’s basic pay, unless
the damage or loss is caused by your gross neglect or willful misconduct; in such a case, you are
liable for the full amount of the damage or loss, which could amount to thousands of dollars. You
are grossly negligent if you act in a reckless or wanton manner, or if you are aware that your family
members or persons you allow on the premises are likely to act recklessly and you do not take
proper steps to prevent or minimize such conduct. In other words, if you know that damage is likely
to result from the willful misconduct or reckless behavior of family members or guests, and despite
such knowledge, you fail to exercise available opportunities to prevent or limit the damage, you are
grossly negligent and will be charged for the full amount of the loss.
c. Third, you are not liable for damage consisting only of fair wear and tear, or caused by an act of
God or by the acts of persons other than family members or guests. You are, however,
responsible for damage caused by pets belonging to you or your guests.
d. Fourth, special rules for housing-related reports of survey permit commanders to waive claims
for damage or loss w
hen such is found to be in the best interests of the United States. This waiver
authority is similar to forgiveness of the debt. If you request a waiver and fail to get it, you can
appeal the matter through report of survey channels. If unsuccessful, you can seek redress
through the Army Board for Correction of Military Records.
2. The purpose of the housing liability law is to let us set limits for your liability and to waive claims
in appropriate circumstances. The potentially great liability created by the law makes the question
of insurance very important. However, only you can decide whether your potential risks warrant
the purpose of insurance. The Army does not require it, but you may want insurance for your own
protection and peace of mind.
I have read and understand the policy contained herein.
Assignment: Bldg. ______________ Rm. _________
Current as of 9 NOV 20 (CHI)
click to sign
click to edit