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Get DD 1172-2 2020-2024

Instructions for the DD Form 1172-2 can be found at http //www. cac.mil/docs/1172-2-Instructions. pdf.. RELATIONSHIP ADDRESS 66. CITY 68. ZIP CODE 67. STATE 69. COUNTRY SECTION VI - RECEIPT Receipt of new card is acknowledged. DD FORM 1172-2 JAN 2014 73. INSTRUCTIONS The instructions for completing the DD Form 1172-2 should be closely followed to ensure accurate data collection and to preclude overcollection 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. 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. For a complete list of DEERS routine uses visit http //privacy. Chapter 23 E.O. 9397 E.O. 10450 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. Section 301 10 U.S.C. chapter 147 10 U.S.C. Sections 1061 - 1065 1072 - 1074 1074a - 1074c 1074c 1 1076 1076a 1077 1095 k 2 50 U.S.C. chapter 23 E.O. 9397 E.O. 10450 as amended. PRINCIPAL PURPOSE S To apply for and enroll in the Defense Enrollment Eligibility Reporting System DEERS for DoD benefits and privileges. 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 Jan 31 2017 SECTION I - SPONSOR/EMPLOYEE INFORMATION 2. GENDER 1. NAME Last First Middle 6. PAY GRADE 7. GEN. CAT 8. CITIZENSHIP 4. STATUS 12. CITY Permission to use for benefits notifications 5. ORGANIZATION 10. PLACE OF BIRTH 9. DATE OF BIRTH YYYYMMMDD 11. CURRENT HOME ADDRESS 16. PRIMARY E-MAIL ADDRESS 3. GENDER 1. NAME Last First Middle 6. PAY GRADE 7. GEN* CAT 8. CITIZENSHIP 4. STATUS 12. CITY Permission to use for benefits notifications 5. ORGANIZATION 10. PLACE OF BIRTH 9. DATE OF BIRTH YYYYMMMDD 11. CURRENT HOME ADDRESS 16. PRIMARY E-MAIL ADDRESS 3. SSN OR DOD ID NO. 13. STATE 18. CITY OF DUTY LOCATION 17. TELEPHONE NUMBER Include Area Code/DSN 14. ZIP CODE 15. COUNTRY 19. STATE OF DUTY LOCATION 20. COUNTRY OF DUTY 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* 23. DATE SIGNED YYYYMMMDD 22. SPONSOR/EMPLOYEE SIGNATURE SECTION III - AUTHORIZED BY 24. SPONSORING OFFICE NAME 25.

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