Blank Dd 1172 2 PDF Template
The DD Form 1172-2, also known as the Application for Identification Card/DEERS Enrollment, plays a crucial role in the lives of individuals associated with the Department of Defense (DoD) and Uniformed Services. This form is integral for securing DoD benefits, accessing military installations, and ensuring eligibility for a range of privileges, including healthcare and facility access. The form requires detailed information about the sponsor or employee, including personal identification, organizational affiliations, and status. It also encompasses sections for dependent information, signifying its comprehensive nature in facilitating the DEERS enrollment process. The importance of accuracy and truthfulness in completing this form is underscored by a notary requirement and the implications of providing false information. With the form's validity limited to 90 days post-verification, applicants are encouraged to understand the form's stipulations, deadlines, and the potential consequences of non-compliance. Privacy concerns and instructions are addressed directly within the document, emphasizing the form's adherence to federal privacy laws and the applicant’s responsibility towards accurate disclosure. Overall, the DD Form 1172-2 is a vital document that ensures the continuation of benefits and privileges for service members, retirees, and their dependents, mirroring the broader commitments of the U.S. defense ecosystem to its personnel.
Preview - Dd 1172 2 Form
APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
OMB No.
SECTION I - SPONSOR/EMPLOYEE INFORMATION
1.NAME (Last, First, Middle)
2. GENDER
3. SSN OR DoD ID NO.
4. STATUS
5. ORGANIZATION
6. PAY GRADE
7. GEN. CAT
8. CITIZENSHIP
9. DATE OF BIRTH (YYYYMMDD)
10. PLACE OF BIRTH
11. CURRENT HOME ADDRESS
12. CITY
13. STATE
14. ZIP CODE
15. COUNTRY
16. PRIMARY EMAIL ADDRESS
Permission to use for benefits notifications
17.TELEPHONE NUMBER (Include Area Code/DSN)
18. CITY OF DUTY LOCATION
19.STATE OF DUTY LOCATION
20. COUNTRY OF DUTY LOCATION
SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS
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.)
22. SPONSOR/EMPLOYEE SIGNATURE
23. DATE SIGNED (YYYYMMDD)
SECTION III - AUTHORIZED BY
24. SPONSORING OFFICE NAME |
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25. CONTRACT NUMBER |
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26. SPONSORING OFFICE ADDRESS |
27. SPONSORING OFFICE TELEPHONE |
28. OFFICE EMAIL ADDRESS |
29. OVERSEAS ASSIGNMENT (Country) |
(Street, City, State, ZIP Code) |
NUMBER (Include Area Code/DSN) |
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30.OVERSEAS ASSIGNEMENT BEGIN DATE (YYYYMMDD)
31.OVERSEAS ASSIGNEMENT END DATE (YYYYMMDD)
32.ELIGIBILITY EFFECTIVE DATE (YYYYMMDD)
33.ELIGIBILITY EXPIRATION DATE (YYYYMMDD)
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.
34. SPONSORING OFFICIAL NAME (Last, First, Middle)
35. UNIT/ORGANIZATION NAME
36. TITLE
37. PAY GRADE
38. SIGNATURE
39. DATE VERIFIED (YYYYMMDD)
SECTION IV - VERIFIED BY
40.VERIFYING OFFICIAL NAME (Last, First, Middle Initial)
41. SITE IDENTIFICATION
42.TELEPHONE NUMBER (Include Area Code/DSN)
43. SIGNATURE
SECTION V - DEPENDENT INFORMATION (Attach additional pages if necessary)
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44. NAME (Last, First, Middle) |
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45. GENDER |
46. DATE OF BIRTH (YYYYMMDD) |
47. RELATIONSHIP |
48. SSN OR DoD ID NO. |
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49. CURRENT HOME ADDRESS |
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50. PRIMARY EMAIL |
Permission to use for benefits |
51. TELEPHONE NUMBER |
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A |
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ADDRESS |
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notifications (18 and above) |
(Include Area Code/DSN) |
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52. CITY |
53. STATE |
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54. ZIP CODE |
55. COUNTRY |
56. ELIGIBILITY EFFECTIVE DATE |
57. ELIGIBILITY EXPIRATION DATE |
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(YYYYMMDD) |
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58. NAME (Last, First, Middle) |
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59. GENDER |
60. DATE OF BIRTH (YYYYMMDD) |
61. RELATIONSHIP |
62. SSN OR DoD ID NO. |
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63. CURRENT HOME ADDRESS |
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64. PRIMARY EMAIL |
Permission to use for benefits |
65. TELEPHONE NUMBER |
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B |
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ADDRESS |
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notifications (18 and above) |
(Include Area Code/DSN) |
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66. CITY |
67. STATE |
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68. ZIP CODE |
69. COUNTRY |
70. ELIGIBILITY EFFECTIVE DATE |
71. ELIGIBILITY EXPIRATION DATE |
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(YYYYMMDD) |
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SECTION VI - RECEIPT
Receipt of new card is acknowledged.
72. SIGNATURE
73. DATE ISSUED (YYYYMMDD)
DD FORM |
PREVIOUS EDITION IS OBSOLETE. |
This form is valid for issue of DoD ID Card for 90 days |
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from date of verification. |
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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
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO A
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
Applicant information is subject to computer matching within the Department of Defense or with other Federal or
DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a Uniformed Services Identification Card and/or
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
DD FORM |
PREVIOUS EDITION IS OBSOLETE. |
This form is valid for issue of DoD ID Card for 90 days |
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from date of verification. |
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Form Data
| Fact | Detail |
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| Purpose | Application for Identification Card/DEERS Enrollment |
| OMB Number | 0704-0415 |
| OMB Approval Expiration | 2023-04-30 |
| Sections | Sponsor/Employee Information, Declaration and Remarks, Authorized by, Verified by, Dependent Information, Receipt |
| Agency Disclosure Notice | Estimated average response time is 3 minutes |
| Privacy Act Statement Authority | 10 U.S.C. Chapter 53, 54, 50 U.S.C. Chapter 23, DoD Instruction 1341.2, Homeland Security Presidential Directive 12, E.O. 9397 (SSN) as amended |
| Principal Purposes | To enroll in DEERS for DoD benefits and privileges |
| Routine Uses | Sharing with Federal and State agencies, civil and criminal litigation, access to facilities |
| Additional Routine Uses | Found in DMDC 02 system of records notice |
| Disclosure | Voluntary, but necessary for issuance of Uniform Services Identification Card |
| Penalty for False Statements | Fine up to $10,000 or imprisonment up to five years or both |
Instructions on Utilizing Dd 1172 2
Filling out the DD Form 1172-2 is an important step for securing identification cards and enrollment into the Defense Enrollment Eligibility Reporting System (DEERS) for members of the Department of Defense (DoD) and their dependents. This process allows individuals to access benefits and privileges provided by the DoD. The form requires careful attention to detail and accuracy to ensure eligibility and avoid delays. The following steps are designed to guide you through filling out the form correctly.
- Start with SECTION I - SPONSOR/EMPLOYEE INFORMATION. Enter the sponsor or employee's full name (last, first, middle) in Item 1, followed by their gender in Item 2, and Social Security Number (SSN) or DoD Identification Number in Item 3.
- Complete Items 4 through 10 with the sponsor's status, organization, pay grade, general category (Gen. Cat.), citizenship, date of birth (in YYYYMMDD format), and place of birth.
- For Items 11 through 16, provide the current home address, including city, state, ZIP code, and country. Also, include the primary email address and indicate permission for benefits notifications.
- Enter the telephone number, including area code or DSN, in Item 17. Then provide the city, state, and country of the duty location in Items 18 through 20.
- Move to SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS. In Item 21, include any necessary remarks and provide the sponsor/employee signature, date signed (YYYYMMDD), and, if required, notary signature and seal in Items 22 and 23.
- In SECTION III - AUTHORIZED BY, Items 24 through 38, complete the information related to the Sponsoring Office, including contract number, address, email, and specific details about any overseas assignments. A sponsoring official must fill in their name, organization, title, pay grade, signature, and the date verified.
- For SECTION IV - VERIFIED BY, a verifying official must provide their name, site identification, telephone number, signature, and the date verified in Items 40 through 43.
- SECTION V - DEPENDENT INFORMATION is required if dependents need benefits or sponsorship. For each dependent, fill in their name, gender, date of birth, relationship to the sponsor, SSN or DoD ID Number, current home address, email, phone number, and eligibility dates. Use additional pages if necessary.
- In the final SECTION VI - RECEIPT, the individual receiving the new card must acknowledge receipt with a signature and provide the date issued (YYYYMMDD).
After completing all relevant sections, review the form to ensure all information is correct and complete. Submit the completed form to a Real-Time Automated Personnel Identification System (RAPIDS) workstation for processing. This step finalizes the application for a DoD ID Card and DEERS enrollment, granting access to essential benefits and privileges.
Obtain Answers on Dd 1172 2
If you're dealing with the DD Form 1172-2, you likely have some questions. Here are answers to some of the most common ones:
- What is the DD Form 1172-2 used for?
- How do I fill out the DD Form 1172-2?
- Where do I submit the completed DD Form 1172-2?
- What happens if I don't fill out the DD Form 1172-2 accurately?
- Is there an expiration date for the DD Form 1172-2?
The DD Form 1172-2 is primarily used to apply for and enroll in the Defense Enrollment Eligibility Reporting System (DEERS). This is crucial for military members, retirees, and their dependents to access benefits and privileges. These include medical coverage, DoD identification cards, and permission to enter DoD installations, buildings, and facilities. It's also needed to access DoD computer systems and networks.
Filling out the DD Form 1172-2 should be done carefully to ensure all information is accurate. First, read the Agency Disclosure Notice, Privacy Act Statement, and Instructions. The form requires detailed information about the sponsor/employee and, if applicable, dependents. This includes personal information, contact details, and eligibility information. Make sure to sign and date the form in the appropriate sections. Detailed instructions can be found on the official CAC website.
Once you've completed the form, do not return it to the initial distribution organization. Instead, take your completed form to a Real-Time Automated Personnel Identification System (RAPIDS) workstation. These are located on most military installations and are where ID cards are issued and managed.
Filling out the form inaccurately can result in delays or denial of DoD benefits and privileges. It's important to provide all requested information correctly to avoid issues with enrollment in DEERS and access to benefits. Additionally, presenting false information can lead to penalties, including fines and imprisonment.
Yes, the form explicitly states that it is valid for the issue of a DoD ID Card for 90 days from the date of verification. Therefore, it's important to process the form in a timely manner to ensure you or your dependents receive your identification cards and can access your benefits without interruption.
Remember, the DD Form 1172-2 is a vital piece of documentation for members of the military community. Taking the time to fill it out accurately ensures access to the benefits and support services you've earned.
Common mistakes
Filling out the DD Form 1172-2, which is crucial for applying for an identification card and DEERS enrollment, requires careful attention to detail. Unfortunately, mistakes can happen. Here are four common errors people make:
Not thoroughly reading the provided instructions: The form comes with a detailed instruction sheet that guides the applicant through each section. Overlooking these instructions can lead to misunderstanding the requirements or filling out sections inaccurately.
Incomplete or inaccurate sponsor/employee information: Section I demands precise information about the sponsor or employee. Errors in providing correct names, dates, and identification numbers or missing details can cause delays or rejection of the application.
Failure to attach supporting documentation in Section II: This section requires applicants to cite legal documentation for verification purposes. Not attaching the required documents, or providing incomplete documentation, can hinder the verification process.
Overlooking dependent information: For those sponsoring dependents, Section V must be filled out comprehensively for each dependent. Missing or incorrect information about dependents can affect their eligibility and access to benefits.
Avoiding these errors can significantly streamline the process of obtaining a DoD ID Card and ensuring enrollment in DEERS, thereby facilitating access to entitled benefits and privileges more efficiently.
Documents used along the form
When individuals or their families become part of the Department of Defense (DoD) through employment, service, or relationship to someone in service, specific forms and documents become an integral part of their administrative processes. The DD Form 1172-2 is a primary document for applying for and enrolling in the Defense Enrollment Eligibility Reporting System (DEERS) and for obtaining a DoD Identification Card. Along with this form, several other documents are frequently required to complete the enrollment process or to supplement the information provided therein. Understanding these forms and their purposes can help streamline the administrative processes involved.
- DD Form 214: This document is the Certificate of Release or Discharge from Active Duty. It is one of the most important documents for military personnel post-service as it is required for various benefits, including VA loans and health services, and often accompanies the DD Form 1172-2 for veterans.
- DD Form 2656: The Data for Payment of Retired Personnel form is utilized by retiring service members. It is essential for setting up retirement pay and benefits, and it often needs to be filed in conjunction with the DD Form 1172-2 when retirement benefits are being processed.
- Birth Certificate or Naturalization Certificate: To verify the identity and citizenship of the applicant, a birth or naturalization certificate may be required. This is particularly relevant when enrolling dependents in DEERS.
- Marriage Certificate: For a spouse to be eligible for the benefits and privileges associated with the DD Form 1172-2, a marriage certificate is often required to prove the lawful marriage to the service member or DoD employee.
- Power of Attorney (POA): This legal document might be necessary if the service member or DoD employee is not present and a spouse or another family member is initiating or updating DEERS enrollment on their behalf.
- Court Order for Child Support, Alimony, or Divorce: These documents might be required to establish the eligibility of dependents for benefits, especially in situations where child support or alimony is involved.
Each of these documents plays a crucial role in ensuring that the benefits and privileges provided by the Department of Defense are accessible to those who are eligible. Whether it's a veteran transitioning back to civilian life, a retiree seeking to set up their retirement pay, or a family member needing access to medical benefits, the proper completion and submission of these forms and documents facilitate a smoother interaction with military and DoD administrative systems. Understanding the purpose and requirements of each can significantly aid individuals in navigating the complexities of military benefits administration.
Similar forms
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The SF-86 Form, "Questionnaire for National Security Positions," is similar to the DD Form 1172-2 in that it collects detailed personal information, including citizenship, education, and employment history, to assess eligibility. Both forms serve as a means to access certain federal benefits and privileges, though the SF-86 focuses on security clearance for government positions.
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The I-9 Form, "Employment Eligibility Verification," also parallels the DD Form 1172-2 by requiring personal and citizenship information to verify eligibility, in this case, for employment in the United States. While the DD Form 1172-2 is specific to Department of Defense benefits, both forms mandate detailed personal data to access certain rights or services.
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The VA Form 10-10EZ, "Application for Health Benefits," shares similarities with the DD Form 1172-2 as it is used by veterans to apply for medical benefits through the Department of Veterans Affairs. Both forms gather personal and eligibility information to determine qualification for benefits within their respective departments.
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The DS-11 Form, "Application for a U.S. Passport," although used for international travel, requires detailed personal information similar to the DD Form 1172-2, such as name, SSN, and citizenship status. Both forms are gateways to privileges—ID cards for military benefits and passports for travel.
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The CMS-40B Form, "Application for Enrollment in Medicare Part B (Medical Insurance)," resembles the DD Form 1172-2 by collecting personal information to establish eligibility for health insurance benefits. While the CMS-40B targets individuals 65 or older or with certain disabilities, both forms facilitate access to government-provided services.
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The N-400 Form, "Application for Naturalization," is akin to the DD Form 1172-2 in its role of collecting personal data, including current home address and date of birth, to determine eligibility for U.S. citizenship. Both are critical steps in accessing a set of rights and benefits provided by the U.S. government.
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The ATF Form 4473, "Firearms Transaction Record," while distinct in purpose from the DD Form 1172-2, collects personal identification and eligibility information to regulate the lawful sale and ownership of firearms. Just like the DD Form 1172-2 ensures eligibility for defense benefits, the ATF Form 4473 ensures eligibility for firearm ownership under federal law.
Dos and Don'ts
When completing the DD Form 1172-2, it's crucial to adhere to specific guidelines to ensure the application process is smooth and successful. Here are essential things you should and shouldn't do:
Do's:- Read all instructions carefully before starting the application to avoid any mistakes that could delay the process.
- Ensure all information is accurate and up-to-date, particularly your contact information and any documentation related to your eligibility.
- Double-check the form for any errors or incomplete sections before submission to ensure all required fields are properly filled out.
- Make sure the signature and date sections are duly completed, as an unsigned or undated form may be considered invalid.
- Keep a copy of the completed form for your records, as it could be useful for future reference or in case any issues arise.
- Avoid leaving any fields blank; if a section does not apply, mark it as "N/A" (not applicable) to indicate that you did not overlook it.
- Do not guess information; if unsure about a specific detail, seek clarification or verify the correct information before filling it out.
- Refrain from using corrections fluid or tape; instead, start with a new form if you need to make significant changes, to maintain legibility.
- Avoid submitting the form without first reviewing the Agency Disclosure Notice, Privacy Act Statement, and all instructions provided to ensure compliance.
- Do not rush through the process; taking your time to fill out the form carefully can prevent delays caused by the need for corrections.
Misconceptions
When navigating the complexities of the DD Form 1172-2, understanding what it is and what it’s not can help streamline the process for you. Here are six common misconceptions about this particular form:
- It’s only for military personnel: While it's commonly associated with service members, the DD Form 1172-2 is actually required for all individuals, including dependents, who need to be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) for receiving DoD benefits and privileges.
- It’s valid indefinitely once signed: Contrary to what some may think, this form grants eligibility for a DoD ID card for only 90 days from the date of verification. After that period, re-verification may be necessary.
- Everyone knows how to fill it out: Filling out the form can be complicated. Instructions are provided and should be followed carefully to avoid errors and ensure that information is correctly captured.
- The form is only completed once: Life events such as marriage, birth of a child, or retirement can change one’s eligibility status. Therefore, the DD Form 1172-2 might need to be completed multiple times throughout an individual's or dependent's eligibility period.
- Failure to complete won’t have consequences: The form is voluntary; however, not providing the information can result in denial of a Uniformed Services ID Card, non-enrollment in DEERS, and refusal of access to DoD facilities and networks.
- Any mistakes can easily be corrected later: While some errors can be corrected after submission, providing accurate information the first time is crucial. Mistakes can delay processing times, and in some cases, may require restarting the enrollment process.
Understanding these misconceptions can help in navigating the process more effectively, ensuring that all eligible individuals receive their benefits without unnecessary delays.
Key takeaways
When completing the DD Form 1172-2, Application for Identification Card/DEERS Enrollment, it is crucial to read and understand the Agency Disclosure Notice, Privacy Act Statement, and provided Instructions. These sections are designed to help the applicant provide the necessary information accurately and legally.
Accuracy is key when filling out the form. The information provided must be true and correct to the best of the applicant's knowledge, as this form is used to determine eligibility for Department of Defense benefits and privileges, including medical coverage and access to DoD installations.
It is important to note that the form requires personal identification information, such as Social Security Number (SSN) or DoD Identification Number, and other sensitive data. This requirement underscores the importance of safeguarding the form to protect one’s personal information.
- The form must be signed and dated by the sponsor/employee, indicating a declaration that the information provided is accurate. If the signature is not done in the presence of an authorizing official, it has to be notarized.
- Section IV, which covers dependent information, should only be completed if benefits or sponsorship is being requested for/by an eligible sponsor or their dependents. This includes information on each dependent's name, relationship to the sponsor, and other personal details.
- The effectiveness of this form is time-sensitive; it is valid for the issue of a DoD ID Card for 90 days from the date of verification. This limitation highlights the importance of timely submission and processing.
- Failure to provide complete and accurate information may result in the denial of a Uniformed Services Identification Card and/or non-enrollment in DEERS, and refusal to grant access to DoD installations, buildings, facilities, computer systems, and networks.
For those unsure about any section of the form or requiring guidance, it is advisable to seek assistance from a real-time automated personnel identification system work station or visit the official website for the DD Form 1172-2 instructions. This proactive approach can help ensure that the application process is smooth and error-free.
Remember, presenting false claims or making false statements in connection with claims can result in significant penalties, including fines or imprisonment. It emphasizes the necessity of honesty and thoroughness when completing the DD Form 1172-2.
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