START
CORRECT
CANCEL
STOP
CHANGE
RECERTIFICATION
REPORT
6.
5.
DUTY LOCATION
(Include Station, Name, City, State, and Zip Code)
I certify ALL information regarding this authorization is correct. I will immediately notify the FAO/HRO of any changes in the information above, due to divorce,
marriage, death, living in government quarters etc, which could affect by BAQ or VHA entitlement.
IMPORTANT: Making a false statement or claim against the US Government is punishable by courts-martial. The penalty for willfully making a false claim or a false
statement in connection with claims is a maximum fine of $10,000 or imprisonment for 5 years, or both.
PRIVACY ACT STATEMENT
AUTHORITY:
PRINCIPLE PURPOSE:
ROUTINE USE:
DISCLOSURE IS VOLUNTARY:
AUTHORIZATION TO START, STOP, OR CHANGE
BASIC ALLOWANCE FOR QUARTERS (BAQ),
AND/OR VARIABLE HOUSING ALLOWANCE (VHA)
For use of this form, see AR 37-104-4; the proponent agency is ASA (FM)
37 USC 403; Public Law 96-343; EO 9397.
To start, adjust or terminate military member's entitlement
to basic allowance for quarters (BAQ) and/or
variable housing allowance (VHA).
DATE 15.DATE 13.
Landlord's Name and Address: Rental/Residential Address:
(3)
MARITAL/DEPENDENCY STATUS
(2)
(4)
(2)
c. b. a.
(1)
(2)
(3)
(3)
(4)
(Member in grade E7 and
above)
(2) (1)
(3)(2)
(4)
(1)
(5)
(6)
c.
a.
d.
b. INADEQUATE
(see blocks (1), (2) & (4))
QUARTERS ASSIGNMENT/AVAILABILITY
e.
DEPENDENT CHILD
(see blocks (4), (5) & (6))
c. b.
d.
a.
DATE/ACTION
(YYYYMMDD)
9.
GRADE SOCIAL SECURITY NUMBER
4.
WITHOUT DEPENDENTS
If you check "OTHER" above, prepare DD Form 137 to establish dependency.
MEMBER'S SIGNATURE
EXPENSES, IF AUTHORIZED, I AM REQUESTING VHA BASED ON
If child support received from another military member, complete (1), (2) & (3).
CERTIFICATION OF DEPENDENT SUPPORT
BAQ TYPE
WITH DEPENDENTS PARTIAL
TRANSIENT
(see block (3))
ADEQUATE
(see block (1))
NOT AVAILABLE
QUARTERS
NO.
FAIR RENTAL
VALUE $
CERTIFYING OFFICER'S SIGNATURE
Sharer/Lease Information
Effective Date: Expiration Date: Landlord's Phone No.
My permanent duty station: My dependent's location: Both my permanent duty station and dependent's location.
DOB OF CHILDREN
DependentMember
TOTALS
Monthly Expenses:
Insurance
Other
RELATIONSHIPNAME OF DEPENDENT/SHARER
Spouse/Former
Spouse SSN
Child in
Custody of:
SINGLE
LEGALLY SEPARATED
Member Spouse Former Spouse Other
Spouse/Former
Spouse Duty Station
Date of Marriage,
Divorce/Separation
7.
8.
10.
COMMANDER
DETERMINATION
(Attached)
MEMBER ELECTION
12.
11.
Address Information
2.
TYPE OF ACTION
3.
FROM:
16.
(1)(1)
14.
DA FORM 5960, SEP 1990
REPLACES DA FORM 3298, JUL 80 AND DA FORM 5545, JUL 86 WHICH ARE OBSOLETE
APD LC v2.04ES
1.
NAME (Last, First, MI)
(see blocks (1), (2) & (3))
DEPENDENTS/SHARERS (Continue on back if required)
Number of Sharers (show name(s) and address in block 10.)
Mortgage (PITI) or Rent
COMPLETE CURRENT ADDRESS
(Include ZIP Code)
DIVORCED (see
blocks (1), (2) & (3))
(see blocks (1), (2) & (3))
To adjust member's military pay record, information may
be disclosed to Army components, such as USAFAC,
major commands, and other Army installations; to other
DOD components; other federal agencies such as IRS,
Social Security Administration and VA, GAO, members
of Congress; State and local government; US and State
courts, and various law enforcement agencies. Social
Security Number (SSN) is used for positive identification.
Nondisclosure may result in nonpayment of BAQ and/or
VHA. Disclosure of your SSN is voluntary. However, this
form will not be processed without your SSN because
the Army identifies you for pay purposes by your SSN.
I certify that I provide, or am will to provide adequate support for the above named dependents. I am aware that failure to support the above named
dependents may result in stopping BAQ and recouping BAQ for any prior periods/nonsupport.
IAW service regulations, I certify that the dependency status of my primary dependents, on whose behalf I am receiving BAQ, has not changed so as to affect
my entitlement thereto for the period
TO:
MARRIED
