DHS Form CG-5267 Application for Assignment to Military Housing

Form CG-5267 is a U.S. Department of Homeland Security form also known as the "Application For Assignment To Military Housing". The latest edition of the form was released in January 1, 2009 and is available for digital filing.

Download an up-to-date fillable Form CG-5267 in PDF-format down below or look it up on the U.S. Department of Homeland Security Forms website.

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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
NO
NO
YES
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
NO
YES
16a. ARE YOU ENROLLED IN THE CG SPECIAL NEEDS
16b. IF SO, LIST DEPENDENTS WITH SPECIAL NEEDS.
PROGRAM
NO
YES
17a. DO YOU HAVE PETS
17b. IF SO, WHAT KIND
17c. AGE
17d. WEIGHT
NO
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
Reset
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
NO
NO
YES
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
NO
YES
16a. ARE YOU ENROLLED IN THE CG SPECIAL NEEDS
16b. IF SO, LIST DEPENDENTS WITH SPECIAL NEEDS.
PROGRAM
NO
YES
17a. DO YOU HAVE PETS
17b. IF SO, WHAT KIND
17c. AGE
17d. WEIGHT
NO
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
Reset
P AGE 2 OF CG- 5267 ( 01-09)
SECTION B - HOUSING AUTHORITY ACTION
1. APPLICATION EFFECTIVE DATE
2. DATE APPLICATION RECEIVED
3. DATE DD-1747 SENT TO APPLICANT
4. WAITING LIST PLACED ON
5. EFFECTIVE DATE
6. APPLICANT NOT PLACED ON WAITING LIST (Reason)
7. APPLICANT ASSIGNED TO (Housing unit )
8. DATE OF ASSIGNMENT
9. BAH TERMINATION EMAIL COMPLETED ON (Date)
INSTRUCTIONS
SECTION A - APPLICATION
ALL BLOCKS ARE SELF EXPLANATORY.
THE APPLICATION MUST BE DATED AND SIGNED BY MEMBER.
SECTION B - HOUSING AUTHORITY ACTION
TO BE COMPLETED BY HOUSING AUTHORITY WHO WILL ACKNOWLEDGE RECEIPT
OF APPLICATION, MAIL DD-1747, AND PLACE MEMBER ON WAITING LIST (if applicable)
OR ADVISE REASONS MEMBER NOT PLACED ON WAITING LIST.
Reset

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