Dd 2367 Form – Fill Out and Use This PDF

PART A - IDENTIFICATION AND HOUSING INFORMATION

	1. SERVICEMEMBER				3. SERVICEMEMBER' S RESIDENCE ADDRESS (Street, Apt . No., City,
					Country)
	a. NAME (Last, First, Middle Initial)
	b. PAY GRADE			c. SSN	4. EFFECTIVE DATE OF LEASE/RENTAL/SALE AGREEMENT
					(YYYYMMDD)
	d. DUTY STATION OR HOMEPORT				5. IN WHAT CURRENCY IS YOUR RENT OR MORTGAGE PAID? (X one)
	(1) St at ion Name				(See Instructions on reverse side if you pay rent three or more months in advance.)
						a. LOCAL CURRENCY (Specify name of currency. Report amount in Item 6.)
	(2) Cit y					b. U.S. DOLLARS
					6. X THE APPROPRIATE BOX TO INDICATE WHETHER YOUR
					RESIDENCE IS LEASED OR OWNED AND GIVE THE MONTHLY
	(3) Count ry			(4) Dut y Phone
					RENTAL AMOUNT OR THE PURCHASE PRICE IN THE CURRENCY
					YOU SPECIFIED IN QUESTION 5.
	2. ARE YOU ENTITLED TO A COST-OF-LIVING OR OVERSEAS					a. LEASED/RENTED (Enter monthly rent below .		If sharing, report
	HOUSING ALLOWANCE FOR DEPENDENTS RESIDING					TOTAL rent, not your share.)
	ELSEWHERE? (X one)
		YES (Specify location)				b. OWNED (Enter original purchase price. Include only cost of home,
						EXCLUDE closing costs, taxes, etc.)
		NO or NOT APPLICABLE
				HOMEOWNERS, SKIP QUESTION 7 AND GO DIRECTLY TO QUESTION 8.
	7. UTILITIES (Excluding telephone) (X appropriate block)				8. TO DETERMINE IF YOU ARE A "SHARER" FOR HOUSING ALLOW-
					ANCE PURPOSES, ENTER AN X IN THE BOX AT LEFT FOR EACH
		a. I SEPARATELY PAY FOR ALL UTILITIES. NONE ARE IN-
					CATEGORY OF INDIVIDUAL OCCUPYING YOUR RESIDENCE. FOR
		CLUDED IN RENTAL/LEASE AGREEMENT WITH LANDLORD.
					EACH CATEGORY YOU X, ENTER THE NUMBER REQUESTED IN
					THE BOX AT RIGHT, THEN RECORD THE TOTAL IN THE BOX AT
		b. I DO NOT SEPARATELY PAY FOR ANY UTILITIES (excluding
					THE BOTTOM. (NOTE: Do not count dependents unless covered by
		telephone). ALL UTILITIES ARE INCLUDED IN RENTAL/LEASE			category c.)
		AGREEMENT AND PAID BY LANDLORD.			X	a. MYSELF			1
		c. I SEPARATELY PAY FOR SOME UTILITIES (excluding telephone)				b. SPOUSE WHO IS ALSO A SERVICEMEMBER (Enter " 1" )
		AND SOME ARE INCLUDED IN RENTAL/LEASE AGREEMENT
						c. SPOUSE OR OTHER DEPENDENT WHO IS A FEDERAL
		WITH LANDLORD. (Complete items (1) - (5) below indicating
						CIVILIAN EMPLOYEE ENTITLED TO LIVING
		utilities/services of w hich your landlord provides the MAJORITY.)				QUARTERS ALLOWANCE (Enter number)
			(1) Elect ricit y			d. OTHER SERVICEMEMBERS ENTITLED TO A HOUSING
			(2) Heat ing			ALLOWANCE (Enter number)
			(3) Air conditioning (X if w indow units used and landlord			e. EXCLUDING DEPENDENTS, ANY OTHERS NOT
						COVERED ABOVE WHO PAY A PORTION OF THE
			provides electricity.)			RENT, MORTGAGE, AND/OR UTILITIES (Enter number)
			(4) Wat er or Sew er		TOTAL (8a through e) (If result exceeds " 1" , you are considered a
						" sharer" .)			1
			(5) Trash Disposal

9. If Block 8.b. or 8.d. is marked, report their full name(s), Social Security Number(s) and Branch of Service in "Remarks" on reverse.

PART B - CERTIFICATIONS

12. CERTIFYING OFFICIAL. I have reviewed this action and certify the entitlement. If applicable to this action, member has read the overseas housing allowance briefing sheet and is aware of his/her entitlements and responsibility to report any changes.

a. TYPE HOUSING ALLOWANCE ACTION (X one)

b. MIHA/MISCELLANEOUS ENTITLEMENT (X one)

(1)

St art

(3)

St op

(5) * Cancel

(1) Init ial

(2) Subsequent

(3) None

(2)

Change

(4)

Correct

(6) * Report

c. EFFECTIVE DATE OF ACTION (YYYYMMDD)

* For Air Force use only

d. DOES MEMBER HAVE COMMAND-SPONSORED DEPENDENTS IN AREA OF PERMANENT DUTY STATION?

(1) Yes

(2) No

e. SIGNATURE

f . TITLE

g. DATE SIGNED

(YYYYMMDD)

PRIVACY ACT STATEMENT

AUTHORITY: 37 USC Sect ion 405, and EO 9397.

PRINCIPAL PURPOSE(S): To det ermine eligibilit y f or, t o st art , adjust or t erminat e Overseas Housing Allow ance.

ROUTINE USE(S): In addit ion t o being used by of f icials and employees of t he applicant ' s Unif ormed Service in det ermining eligibilit y, t he inf ormat ion provided herein may be provided t o law enf orcement personnel invest igat ing t hose suspect ed of

f raudulent ly obt aining allow ances. Inf ormat ion may also be disclosed under cert ain circumst ances t o ot her Federal agencies, members of Congress, St at e and local government , and U.S. and St at e court s.

DISCLOSURE: Volunt ary; how ever, f ailure t o provide SSN may preclude t imely considerat ion of your request f or an allow ance det erminat ion.

WARNING: Making a f alse st at ement or claim against t he U.S. Government is punishable by court s-mart ial.

The penalt y f or w illf ully making a f alse claim or a f alse st at ement in connect ion w it h claims is a maximum f ine of $10,000 or imprisonment f or f ive years, or bot h.

SPECIAL INSTRUCTIONS FOR MEMBERS PAYING THREE OR MORE MONTHS RENT IN ADVANCE

In cert ain count ries it is cust omary t o pay advance rent rat her t han mont h-t o-mont h rent . If you pay your rent more t han t hree mont hs in advance, X block 5b. (U.S. Dollars) even t hough you paid your advance rent in local currency. In Part C,

"Remarks," ent er t he f ollow ing inf ormat ion:

(1)" Rent paid _____ mont hs in advance."

(2)Amount of advance rent (in local currency, if t hat is how you paid).

(3)Exchange rat e at w hich you convert ed your dollars t o local currency t o pay t he advance rent , if applicable. Comput e mont hly rent as f ollow s and report in It em 6.a.:

(1)Divide advance rent by number of mont hs rent paid in advance t o det ermine mont hly rent .

(2)If applicable, convert mont hly rent t o dollars by dividing by exchange rat e at w hich you convert ed your dollars t o local currency.

Those paying rent in advance should realize t hat rent al ceilings set by t he Depart ment of Def ense may decrease due t o periodic exchange rat e f luct uat ions. Accordingly, t heir OHA, w hich is comput ed as a mont hly ent it lement , may also decrease during t he mont hs w hen rent al payment s are not act ually being made.

If upon expirat ion of t he advance rent al period t he member must again pay rent t hree or more mont hs in advance, anot her

DDForm 2367 must be complet ed unless t he derived rent al amount previously report ed in It em 6.a. remains unchanged.

PART C - REMARKS

DD FORM 2367 (BACK), MAY 1999