Fillable Form 20230430: APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT (Washington Headquarters Services)

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Form 20230430: APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT (Washington Headquarters Services)

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The Form 20230430: APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT (Washington Headquarters Services) form is 1 page long and contains:

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  • 3 check-boxes
  • 62 other fields

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PREVIOUS EDITION IS OBSOLETE.
This form is valid for issue of DoD ID Card for 90 days
from date of verification.
DD FORM 1172-2, APRIL 2020
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
20230430
SECTION I - SPONSOR/EMPLOYEE INFORMATION
1. NAME (Last, First, Middle)
2. GENDER 3. SSN OR DoD ID NO. 4. STATUS 5. ORGANIZATION
6. PAY GRADE 7. GEN. CAT 8. CITIZENSHIP
9. DATE OF BIRTH (YYYYMMDD)
10. PLACE OF BIRTH
11. CURRENT HOME ADDRESS 12. CITY
13. STATE
14. ZIP CODE
15. COUNTRY
16. PRIMARY EMAIL ADDRESS
Permission to use for benefits notifications
17. TELEPHONE NUMBER
(Include Area Code/DSN)
18. CITY OF DUTY LOCATION 19. STATE OF
DUTY LOCATION
20. COUNTRY OF DUTY LOCATION
SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS
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 (YYYYMMDD)
SECTION III - AUTHORIZED BY
24. SPONSORING OFFICE NAME 25. CONTRACT NUMBER
26. SPONSORING OFFICE ADDRESS
(Street, City, State, ZIP Code)
27. SPONSORING OFFICE TELEPHONE
NUMBER (Include Area Code/DSN)
28. OFFICE EMAIL ADDRESS
29. OVERSEAS ASSIGNMENT (Country)
30. OVERSEAS ASSIGNMENT
BEGIN DATE (YYYYMMDD)
31. OVERSEAS ASSIGNMENT
END DATE (YYYYMMDD)
32. ELIGIBILITY EFFECTIVE DATE
(YYYYMMDD)
33. ELIGIBILITY EXPIRATION DATE
(YYYYMMDD)
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.
34. SPONSORING OFFICIAL NAME (Last, First, Middle)
35. UNIT/ORGANIZATION NAME
36. TITLE 37. PAY GRADE 38. SIGNATURE
39. DATE VERIFIED (YYYYMMDD)
SECTION IV - VERIFIED BY
40. VERIFYING OFFICIAL NAME (Last, First, Middle Initial)
41. SITE IDENTIFICATION
42. TELEPHONE NUMBER
(Include Area Code/DSN)
43. SIGNATURE
SECTION V - DEPENDENT INFORMATION (Attach additional pages if necessary)
44. NAME (Last, First, Middle)
45. GENDER
46. DATE OF BIRTH (YYYYMMDD)
47. RELATIONSHIP 48. SSN OR DoD ID NO.
A
49. CURRENT HOME ADDRESS
50. PRIMARY EMAIL
ADDRESS
Permission to use for benefits
notifications (18 and above)
51. TELEPHONE NUMBER
(Include Area Code/DSN)
52. CITY
53. STATE
54. ZIP CODE
55. COUNTRY
56. ELIGIBILITY EFFECTIVE DATE
(YYYYMMDD)
57. ELIGIBILITY EXPIRATION DATE
(YYYYMMDD)
58. NAME (Last, First, Middle)
59. GENDER
60. DATE OF BIRTH (YYYYMMDD)
61. RELATIONSHIP 62. SSN OR DoD ID NO.
B
63. CURRENT HOME ADDRESS 64. PRIMARY EMAIL
ADDRESS
Permission to use for benefits
notifications (18 and above)
65. TELEPHONE NUMBER
(Include Area Code/DSN)
66. CITY
67. STATE
68. ZIP CODE
69. COUNTRY
70. ELIGIBILITY EFFECTIVE DATE
(YYYYMMDD)
71. ELIGIBILITY EXPIRATION DATE
(YYYYMMDD)
SECTION VI - RECEIPT
Receipt of new card is acknowledged.
72. SIGNATURE
73. DATE ISSUED (YYYYMMDD)
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PREVIOUS EDITION IS OBSOLETE.
This form is valid for issue of DoD ID Card for 90 days
from date of verification.
DD FORM 1172-2, APRIL 2020
AGENCY DISCLOSURE NOTICE
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, at whd.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL IDENTIFICATION SYSTEM WORK STATION.
PRIVACY ACT STATEMENT
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. Additional Routine Uses can be found in system of records notice DMDC 02, at: https://dpcld.defense.gov/Portals/49/Documents/Privacy/
SORNs/OSDJS/DMDC-02-DoD.pdf?ver=2019-12-09-111827-743
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.
INSTRUCTIONS
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/Portals/53/Documents/1172-2-Instructions.pdf.
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Form 20230430: APPLICATION FOR IDENTIFICATION CARDDEERS ENROLLMENT (Washington Headquarters Services)

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Completed 21 November 2021

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