Fillable Application For Assignment To Military Housing printable pdf download

U.S. DEP ARTME NT OF

APPLICATION FOR ASSIGNMENT TO MILITARY HOUSING

HOMELAND SECURITY

U.S. COAST GUARD

(Instructions for preparation of this form are contained on page 2)

C G-5267 (01-09)

PRIVACY ACT STATEMENT

IN ACCORDANCE WITH 5 USC 552(E)(3), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST

GUARD.

1. AUTHORITY:

SECTION 515 P.L. 84-161, AS AMENDED (10 USC 2674) AUTHORIZED SOLICITATION OF THE INFORMATION.

2. PRINCIPAL

TO DETERMINE EACH APPLICANT'S ELIGIBILITY FOR ASSIGNMENT TO SUITABLE MILITARY HOUSING ACCOMMODATIONS.

PURPOSE(S):

3. ROUTINE

THE INFORMATION IS USED BY CG HOUSING OFFICE TO EVALUATE THE ASSIGNMENT OF HOUSING ACCOMMODATIONS.

USES:

4. DISCLOSURE:

DISCLOSURE OF THE INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE THE INFORMATION MAY RESULT IN THE INABILITY

OF THE CG HOUSING OFFICE TO PROVIDE SUITABLE HOUSING TO THE APPLICANT AND AT THE MOST EXPEDITIOUS TIME.

DISCLOSURE OF THE INFORMATION HEREIN CONTAINED TO OTHER THAN THE AGENCY IS IN ACCORDANCE WITH THE FREEDOM

OF INFORMATION ACT.

SECTION A - APPLICATION (To be completed by applicant)

1 . AP P LICANT ' S NAM E ( Last, fi r s t, m i ddle i niti al)

2 . EMPLOYEE IDENTIFICATION NUMBER

3 . AP P LICANT ' S RANK/ RAT E

4. CURRENT DUTY STATION AND PHONE NUMBER

5. NEW DUTY STATION AND PHONE NUMBER

6a. EST. DATE OF DEPARTURE

6b. EST. DATE OF ARRIVAL

7. ADDRESS AND PHONE NUMBER WHILE ON LEAVE ENROUTE

8. ENLISTMENT EXPIRES (Date)

9. ON LIST FOR PROMOTION

10a. ON CLASS "A" SCHOOL LIST

10b. IF SO, WHICH LIST

YES

SPONSOR INFORMATION

11a. NAME OF SPONSOR

11b. RANK/RATE

11c. SPONSOR'S DUTY STATION AND PHONE NUMBER

DEPENDENCY INFORMATION (Check appropriate box)

12. MARITAL STATUS

13. I AM SEPARATED FROM MY DEPENDENTS

MARRIED

SINGLE (CG-4170A not applicable)

N/A

VOLUNTARILY

INVOLUNTARILY

DEPENDENTS RESIDING WITH ME

(If more space is needed, continue on plain paper)

14a.

14b. DATE OF BIRTH

14c.

14d.

14e.

(YYYY/MM/DD)

NAME (Last, First, Middle Initial)

SEX

RELATIONSHIP

REMARKS, (handicap, health problems, expected

additions to family, etc.)

YOU MUST ATTACH COPY OF CG-4170A WHICH INDICATES DATES OF APPROVAL OF THOSE DEPENDENTS WHO WILL RESIDE WITH YOU.

ADDITIONAL DEPENDENT INFORMATION

15a. SPOUSE IN SERVICE

15b. IF SO, WHICH SERVICE 15c. CURRENT DUTY STATION AND PHONE NUMBER

15d. EXPECTED DATE HE/SHE WILL JOIN YOU

YES

16a. ARE YOU ENROLLED IN THE CG SPECIAL NEEDS

16b. IF SO, LIST DEPENDENTS WITH SPECIAL NEEDS.

PROGRAM

YES

17a. DO YOU HAVE PETS

17b. IF SO, WHAT KIND

17c. AGE

17d. WEIGHT

YES

GENERAL

UPON ARRIVAL AT YOUR NEW DUTY STATION, IT IS MANDATORY THAT YOU REPORT TO THE HOUSING AUTHORITY SERVING THE AREA PRIOR TO

MAKING ARRANGEMENTS FOR ANY TYPE HOUSING. YOU SHOULD HAVE DD-1747 (previously issued) READY FOR PRESENTATION.

IN THE EVENT ASSIGNMENT TO MILITARY HOUSING BECOMES MANDATORY, THIS IS TO CERTIFY THAT:

I DO

I DO NOT DESIRE A WAIVER TO RESIDE IN CIVILIAN HOUSING

I CERTIFY THAT THE INFORMATION ABOVE IS CORRECT. I HAVE ATTACHED A COPY OF MY ORDERS AND APPROVED

CG-4170A HERETO. CG-4170A N/A FOR SINGLE MEMBERS.

DATE SUBMITTED

APPLICANT'S SIGNATURE

PREVIOUS EDITION IS OBSOLETE

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Application For Assignment To Military Housing

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