DD Form 1172-2 Application for Identification Card/DEERS Enrollment

What Is DD Form 1172-2?

DD Form 1172-2, Application for Identification Card/DEERS Enrollment is a form issued by the Department of Defense (DoD) and used for applying for a variety of Army identification cards, enrolling an individual into the Defense Enrollment Eligibility Reporting System (DEERS) database or when updating an existing DEERS record.

The DD 1172-2 is often incorrectly referred to as the DD Form 1172 or DA Form 1172. The application - sometimes called the DD 1172 DEERS Form - is used to request a DD Form 2, a DD Form 1173, a DD Form 1173-1, a DD Form 2764, a DD Form 2765, and a Common Access Card (CAC) for eligible individuals.

The DD Form 1172-2 March 2017 version is up-to-date and in use today: all previous editions are obsolete and should not be used. A fillable version of the application can be acquired through the chain of command, downloaded from the DoD documentation website or down below.

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APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
OMB No. 0704-0415
OMB approval expires
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
March 31, 2020
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
10. PLACE OF BIRTH
9. DATE OF BIRTH
(YYYYMMMDD)
11. CURRENT HOME ADDRESS
12. CITY
13. STATE 14. ZIP CODE
15. COUNTRY
19. STATE OF DUTY
20. COUNTRY OF DUTY
16. PRIMARY E-MAIL ADDRESS
18. CITY OF DUTY LOCATION
Permission to use for benefits
17. TELEPHONE NUMBER
LOCATION
notifications
LOCATION
(Include Area Code/DSN)
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.)
23. DATE SIGNED (YYYYMMMDD)
22. SPONSOR/EMPLOYEE SIGNATURE
SECTION III - AUTHORIZED BY
24. SPONSORING OFFICE NAME
25. CONTRACT NUMBER
28. OFFICE EMAIL ADDRESS
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
27. SPONSORING OFFICE
29. OVERSEAS ASSIGNMENT
TELEPHONE NUMBER
(Country)
(Include Area Code/DSN)
30. OVERSEAS ASSIGNMENT BEGIN
31. OVERSEAS ASSIGNMENT END
32. ELIGIBILITY EFFECTIVE DATE
33. ELIGIBILITY EXPIRATION DATE
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
(YYYYMMMDD)
(YYYYMMMDD)
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
39. DATE VERIFIED
36. TITLE
37. PAY
38. SIGNATURE
(YYYYMMMDD)
GRADE
SECTION IV - VERIFIED BY
40. VERIFYING OFFICIAL NAME (Last, First, Middle Initial)
41. SITE IDENTIFICATION
43. SIGNATURE
42. TELEPHONE NUMBER
(Include Area Code/DSN)
SECTION V - DEPENDENT INFORMATION
(Attach additional pages if necessary)
45. GENDER
44. NAME (Last, First, Middle)
46. DATE OF BIRTH
47. RELATIONSHIP
48. SSN OR DOD ID NO.
A
(YYYYMMMDD)
49. CURRENT HOME ADDRESS
Permission to use for benefits
50. PRIMARY E-MAIL
51. TELEPHONE NUMBER
notifications (18 and above)
ADDRESS
(Include Area Code/DSN)
52. CITY
53. STATE
54. ZIP CODE
55. COUNTRY
56. ELIGIBILITY EFFECTIVE
57. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
58. NAME (Last, First, Middle)
59. GENDER
61. RELATIONSHIP
62. SSN OR DOD ID NO.
B
60. DATE OF BIRTH
(YYYYMMMDD)
63. CURRENT HOME ADDRESS
Permission to use for benefits
64. PRIMARY E-MAIL
65. TELEPHONE NUMBER
notifications (18 and above)
ADDRESS
(Include Area Code/DSN)
70. ELIGIBILITY EFFECTIVE
71. ELIGIBILITY EXPIRATION
66. CITY
67. STATE
68. ZIP CODE
69. COUNTRY
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
SECTION VI - RECEIPT
Receipt of new card is acknowledged.
72. SIGNATURE
73. DATE ISSUED (YYYYMMMDD)
This form valid for issue of DoD ID Card for 90 days
PREVIOUS EDITION IS OBSOLETE.
DD FORM 1172-2, MAR 2017
from date of verification.
Adobe Designer 9.0
APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
OMB No. 0704-0415
OMB approval expires
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
March 31, 2020
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
10. PLACE OF BIRTH
9. DATE OF BIRTH
(YYYYMMMDD)
11. CURRENT HOME ADDRESS
12. CITY
13. STATE 14. ZIP CODE
15. COUNTRY
19. STATE OF DUTY
20. COUNTRY OF DUTY
16. PRIMARY E-MAIL ADDRESS
18. CITY OF DUTY LOCATION
Permission to use for benefits
17. TELEPHONE NUMBER
LOCATION
notifications
LOCATION
(Include Area Code/DSN)
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.)
23. DATE SIGNED (YYYYMMMDD)
22. SPONSOR/EMPLOYEE SIGNATURE
SECTION III - AUTHORIZED BY
24. SPONSORING OFFICE NAME
25. CONTRACT NUMBER
28. OFFICE EMAIL ADDRESS
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
27. SPONSORING OFFICE
29. OVERSEAS ASSIGNMENT
TELEPHONE NUMBER
(Country)
(Include Area Code/DSN)
30. OVERSEAS ASSIGNMENT BEGIN
31. OVERSEAS ASSIGNMENT END
32. ELIGIBILITY EFFECTIVE DATE
33. ELIGIBILITY EXPIRATION DATE
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
(YYYYMMMDD)
(YYYYMMMDD)
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
39. DATE VERIFIED
36. TITLE
37. PAY
38. SIGNATURE
(YYYYMMMDD)
GRADE
SECTION IV - VERIFIED BY
40. VERIFYING OFFICIAL NAME (Last, First, Middle Initial)
41. SITE IDENTIFICATION
43. SIGNATURE
42. TELEPHONE NUMBER
(Include Area Code/DSN)
SECTION V - DEPENDENT INFORMATION
(Attach additional pages if necessary)
45. GENDER
44. NAME (Last, First, Middle)
46. DATE OF BIRTH
47. RELATIONSHIP
48. SSN OR DOD ID NO.
A
(YYYYMMMDD)
49. CURRENT HOME ADDRESS
Permission to use for benefits
50. PRIMARY E-MAIL
51. TELEPHONE NUMBER
notifications (18 and above)
ADDRESS
(Include Area Code/DSN)
52. CITY
53. STATE
54. ZIP CODE
55. COUNTRY
56. ELIGIBILITY EFFECTIVE
57. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
58. NAME (Last, First, Middle)
59. GENDER
61. RELATIONSHIP
62. SSN OR DOD ID NO.
B
60. DATE OF BIRTH
(YYYYMMMDD)
63. CURRENT HOME ADDRESS
Permission to use for benefits
64. PRIMARY E-MAIL
65. TELEPHONE NUMBER
notifications (18 and above)
ADDRESS
(Include Area Code/DSN)
70. ELIGIBILITY EFFECTIVE
71. ELIGIBILITY EXPIRATION
66. CITY
67. STATE
68. ZIP CODE
69. COUNTRY
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
SECTION VI - RECEIPT
Receipt of new card is acknowledged.
72. SIGNATURE
73. DATE ISSUED (YYYYMMMDD)
This form valid for issue of DoD ID Card for 90 days
PREVIOUS EDITION IS OBSOLETE.
DD FORM 1172-2, MAR 2017
from date of verification.
Adobe Designer 9.0
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, Executive Services Directorate, Directives Division,
Information Management Branch, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0415). Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it
does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL IDENTIFICATION SYSTEM WORK STATION.
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 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
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-
DEERS routine uses, visit:
dod/
Applicant information is subject to computer matching within the Department of Defense or with other Federal or non-Federal agencies.
Matching programs are conducted to assure that an individual eligible under a Federal program is not improperly receiving duplicate benefits
from another program. A beneficiary or former beneficiary who has applied for privileges of a Federal Benefit Program and has received
concurrent assistance under another plan will be subject to adjustment or recovery of any improper payments made or delinquent debts
owed.
DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a Uniformed Services Identification Card and/or
non-enrollment in the Defense Enrollment Eligibility Reporting System, refusal to grant access to DoD installations, buildings, facilities,
computer systems and networks.
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 1172-2 should be closely followed to ensure accurate data collection and to preclude over
collection 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. Instructions for the DD Form 1172-2 can be found at: http://www.cac.mil/Portals/53/Documents/1172-2-
Instructions.pdf.
DD FORM 1172-2 (BACK), MAR 2017

Download DD Form 1172-2 Application for Identification Card/DEERS Enrollment

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DD Form 1172-2 Instructions

The DD 1172-2 Form is divided into six sections. These sections provide information about the employee or sponsor, sponsoring agency and benefits eligibility. All the information being input must be valid and accurate. The penalty for false claims or statements is a fine of up to $10,000, a prison sentence of up to five years or both.

Section I is filled by the applicant and contains personal identifying information including the name, social security number, gender, pay grade, status, and detailed contact information of the individual.

Section II requires additional information regarding the current assignment and the benefits the individual is eligible for and is completed by the applicant or their department or agency.

The third section contains all details and lists contact information regarding the applicant's sponsoring group or agency. This part provides details about the applicant's position and assignment and further information about the sponsoring official: their name, pay grade and title. The section is then signed by a qualified official for authorization.

All personal and contact information about any dependents is listed in the fourth section of the DD 1172-2. The standard form allows listing of two individuals.

The applicant must then acknowledge the receipt of their ID Card in Section V.

A copy of the DD Form 1172-2 must be kept on hand for further reference or to use when filing amended DD 1172-2 Forms in the future.

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