Read the instructions and Privacy Act statement below before completing the form. All responses should be typed
or printed in ink. Submit completed form to:
Office of Commissioned Corps Support Services
ATT: Compensation Branch
5600 Fishers Lane, Room 4-50
Rockville, MD 20857-0001
HEADING: Applicable to all Public Health Service (PHS) Commissioned Corps officers. Self-explanatory.
Item 1: Place an "X" in the box(es) which identifies the action(s) being requested.
Item 2: Self-explanatory.
Item 3: a. Effective date to be entered is the latest of the following dates:
1. call to active-duty date;
2. date of marriage;
3. date individual became an eligible dependent pursuant to established policy;
4. date Government quarters were terminated; or
5. if the purpose of submitting the form is "Recertification" and the last digit of your SSN is 1, enter "1
Jan _____ (year)"; 2, enter "1 Feb _____ (year)"; 3, enter "1 Mar _____ (year)"; 4, enter "1 Apr _____
(year)"; 5, enter "1 May _____ (year)"; 6, enter "1 Jun _____ (year)"; 7, enter "1 Jul _____ (year)"; 8,
enter "1 Aug _____ (year)"; 9, enter "1 Sep _____ (year)"; 0, enter "1 Oct _____ (year)".
b. Enter all eligible dependents. If the address is the same for all dependents, list only once. If additional space is
required, identify dependents on a separate sheet of paper and attach the paper to this form. Include sponsor’s
name and SSN.
Complete only if child(ren) listed in Item 3 is/are not in the officer’s legal custody.
Complete only if dependent(s) listed in Items 3 is/are other than the officer’s legal spouse and/or dependent child(ren)
under 21 years of age. Dependent’s income from other sources must include all wages, compensation, pensions,
annuities, alimony, retirement benefits
, and the reasonable value of gifts and contributions received from others.
Dependent’s monthly expenses should only reflect the dependent’s average living expenses during the past calendar
year which can be documented. You may include a reasonable value for quarters and/or subsistence furnished by
someone other than the dependent. (Reference Commissioned Corps Personnel Manual, Subchapter CC22.)
Complete only if divorced and dependent(s) is/are identified in Item 3.
Complete only if dependent(s) is/are listed in Item 3. The uniformed services include the Army, Navy, Air Force
Marines, Coast Guard, Commissioned Corps of the National Oceanic and Atmospheric Administration, and PHS
PRIVACY ACT NOTICE FOR
PHS COMMISSIONED OFFICER’S REQUEST FOR DEPENDENCY DETERMINATION
This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. 552a). Our authority to collect this information is 37 U.S.C. 403;
42 U.S.C. 202 et seq.; and Executive Order 9397, "Numbering System for Federal Accounts Relating to Individual Persons."
The information provided on this form will become part of record systems 09-40-0001, "PHS Commissioned Corps Personnel Records,"
HHS/PSC/HRS and 09-40-0010, "Pay, Leave, and Attendance Records," HHS/PSC/HRS.
PRINCIPAL PURPOSE AND ROUTINE USES
- This information is used to determine whether an individual’s dependency on a PHS
commissioned officer entitles the officer to additional Basic Allowance for Housing (BAH). This information will be used only as
necessary in personnel and pay administration processes carried out in accordance with established regulations and published notices of
systems of records. Copies of these systems of records may be obtained by contacting the office to which you submit this form.
EFFECTS OF NONDISCLOSURE
- Disclosure of the Social Security Number (SSN) is mandatory under provisions of Executive Order
9397 to obtain benefits and services as or on behalf of a commissioned officer. The SSN is also used to distinguish a record from those of
commissioned officers who may have similar names and dates of birth. Failure to provide the remaining information will result in denial of
this claim, delay and/or errors in determining dependency
, late payment or non-payment, or refund of BAH if payment is based on
erroneous information. All statements are subject to verification.