(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
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:
c. b. a.
(Member in grade E7 and
(see blocks (1), (2) & (4))
(see blocks (4), (5) & (6))
GRADE SOCIAL SECURITY NUMBER
If you check "OTHER" above, prepare DD Form 137 to establish dependency.
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
WITH DEPENDENTS PARTIAL
(see block (3))
(see block (1))
CERTIFYING OFFICER'S SIGNATURE
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
RELATIONSHIPNAME OF DEPENDENT/SHARER
Member Spouse Former Spouse Other
Spouse Duty Station
Date of Marriage,
TYPE OF ACTION
DA FORM 5960, SEP 1990
REPLACES DA FORM 3298, JUL 80 AND DA FORM 5545, JUL 86 WHICH ARE OBSOLETE
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)
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
APD AEM v2.06ES