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AUTHORIZATION TO START, STOP, OR CHANGE |
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PRIVACY ACT STATEMENT |
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BASIC ALLOWANCE FOR QUARTERS |
(BAQ), |
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AUTHORITY: |
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37 USC 403; Public Law 96-343; EO 9397. |
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AND/OR VARIABLE HOUSING ALLOWANCE (VHA) |
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PRINCIPLE PURPOSE: |
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To start, adjust or terminate military member's entitlement |
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For use of this form, see AR 37-104-4; the proponent agency is ASA (FM) |
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to basic allowance for quarters (BAQ) and/or |
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variable housing allowance |
(VHA). |
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1. |
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NAME |
(Last, First, MI) |
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ROUTINE USE: |
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To adjust member's military pay record, information may |
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be disclosed to Army components, such as USAFAC, |
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major commands, and other Army installations; to other |
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DOD components; other federal agencies such as IRS, |
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2. |
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SOCIAL SECURITY NUMBER |
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3. |
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GRADE |
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Social Security Administration and VA, GAO, members |
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of Congress; State and local government; US and State |
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courts, and various law enforcement agencies. Social |
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Security Number (SSN) is used for positive identification. |
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4. |
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TYPE OF ACTION |
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DISCLOSURE IS VOLUNTARY: Nondisclosure may result in nonpayment of BAQ and/or |
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START |
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CANCEL |
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CHANGE |
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REPORT |
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VHA. Disclosure of your SSN is voluntary. However, this |
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form will not be processed without your SSN because |
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the Army identifies you for pay purposes by your SSN. |
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CORRECT |
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STOP |
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RECERTIFICATION |
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5. |
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DUTY LOCATION (Include Station, Name, City, State, and Zip Code) |
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6. DATE/ACTION |
7. |
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BAQ TYPE |
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(YYYYMMDD) |
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WITH DEPENDENTS |
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PARTIAL |
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WITHOUT DEPENDENTS |
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8. |
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MARITAL/DEPENDENCY STATUS |
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9. |
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QUARTERS ASSIGNMENT/AVAILABILITY |
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a. |
SINGLE |
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b. MARRIED |
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c. DIVORCED (see |
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a. |
ADEQUATE |
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b. |
INADEQUATE |
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(see blocks (1), (2) & (3)) |
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blocks (1), (2) & (3)) |
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(see block (1)) |
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(see blocks (1), (2) & (4)) |
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d. |
LEGALLY SEPARATED |
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e. |
DEPENDENT CHILD |
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c. |
TRANSIENT |
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d. |
NOT AVAILABLE |
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(see blocks (1), (2) & (3)) |
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(see blocks (4), (5) & (6)) |
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(see block (3)) |
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(1) |
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Spouse/Former |
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(2) |
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Spouse/Former |
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(3) |
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Date of Marriage, |
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(1) |
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QUARTERS |
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(2) |
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FAIR RENTAL |
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Spouse SSN |
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Spouse Duty Station |
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Divorce/Separation |
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NO. |
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VALUE $ |
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(4) |
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Child in |
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Member |
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Spouse |
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Former Spouse |
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Other |
(3) |
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FROM: |
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TO: |
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Custody of: |
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(4) |
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(5) |
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If you check "OTHER" above, prepare DD Form 137 to establish dependency. |
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MEMBER ELECTION |
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COMMANDER |
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(Member |
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grade E7 and |
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DETERMINATION |
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(6) |
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If child support received from another military member, complete (1), (2) & (3). |
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above) |
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(Attached) |
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10. |
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DEPENDENTS/SHARERS (Continue on back if required) |
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NAME OF DEPENDENT/SHARER |
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COMPLETE CURRENT ADDRESS |
(Include ZIP Code) |
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RELATIONSHIP |
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DOB OF CHILDREN |
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11. |
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CERTIFICATION OF DEPENDENT SUPPORT |
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I certify that I provide, or am will to provide adequate support for the above named dependents. I am aware that failure to support the above named |
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dependents may result in stopping BAQ and recouping BAQ for any prior periods/nonsupport. |
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IAW service regulations, I certify that the dependency status of my primary dependents, on whose behalf I am receiving BAQ, has not changed so as to affect |
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my entitlement thereto for the period |
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12. |
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EXPENSES, IF AUTHORIZED, I AM REQUESTING VHA BASED ON |
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My permanent duty station: |
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My dependent's location: |
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Both my permanent duty station and dependent's location. |
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a. |
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Monthly Expenses: |
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Member |
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Dependent |
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b. |
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Sharer/Lease Information |
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c. |
Address Information |
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(1) |
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Mortgage (PITI) |
or Rent |
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(1) |
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Rental/Residential Address: |
(1) |
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Landlord's Name and Address: |
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(2) |
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Insurance |
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(3) |
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Other |
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(2) |
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Effective Date: |
(3) |
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Expiration Date: |
(2) |
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Landlord's Phone No. |
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TOTALS |
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(4) |
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Number of Sharers |
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(show name(s) and address in block 10.) |
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I certify ALL information regarding this authorization is correct. I will immediately notify the FAO/HRO of any changes in the information above, due to divorce, |
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marriage, death, living in government quarters etc, which could affect by BAQ or VHA entitlement. |
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IMPORTANT: Making a false statement or claim against the US Government is punishable by courts-martial. The penalty for willfully making a false claim or a false |
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statement in connection with claims is a maximum fine of $10,000 or imprisonment for 5 years, or both. |
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13. |
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MEMBER'S SIGNATURE |
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14. DATE |
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15. |
CERTIFYING OFFICER'S SIGNATURE |
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16. DATE |
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