Dd 1172 2 Form – Fill Out and Use This PDF

SECTION I - SPONSOR/EMPLOYEE INFORMATION

SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS

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.)

SECTION III - AUTHORIZED BY

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.

SECTION IV - VERIFIED BY

SECTION V - DEPENDENT INFORMATION (Attach additional pages if necessary)

SECTION VI - RECEIPT

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.