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APPLICATION FOR ASSIGNMENT TO HOUSING (Before completing form, read Privacy Act Statement and Instructions on reverse)
1. TYPE SERVICE DESIRED (X one or both) a. MILITARY HOUSING b. HOUSING REFERRAL **SECTION I - APPLICANT INFORMATION
- NAME OF SPONSOR** (Last, First, Middle Initial) **3. PAY GRADE 4. SSN 5. DOD COMPONENT
- ADDRESS** (Street, City, State, Zip Code) 7. TELEPHONE NUMBER 8. STATUS OF APPLICANT (X one) a. HOME (Area Code) b. DUTY (DSN) a. MILITARY MEMBER b. MILITARY SPOUSE
c. CIVILIAN d. FOREIGN NATIONAL
9. MARITAL STATUS 10. I AM SEPARATED FROM MY DEPENDENTS (X one) a. VOLUNTARILY b. INVOLUNTARILY 11. I REQUEST HOUSING FOR (X one) a. SELF ONLY b. SELF AND DEPENDENTS
SECTION II - MILITARY CAREER INFORMATION (Civilians skip to Item 15.)
14. DATES (Enter in YYMMDD order) a. EFFECTIVE RANK/RATE DATE b. ACTIVE DUTY SERVICE COMPUTATION DATE c. TIME REMAINING ON ACTIVE DUTY d. EFFECTIVE CHANGE IN DUTY STATION e. REPORT DATE f. ESTIMATED FAMILY ARRIVAL DATE
MILITARY APPLICANT MILITARY SPOUSE
**12. INSTALLATION/ORGANIZATION TRANSFERRED FROM
- INSTALLATION/ORGANIZATION TRANSFERRED TO**
SECTION III - DEPENDENT DATA
15. DEPENDENTS RESIDING WITH ME (If more space is needed, continue on plain paper.)
a. NAME (Last, First, Middle Initial) b. DATE OF BIRTH (YYMMDD) c. SEX d. RELATIONSHIP e. REMARKS (Handicap, health problems, expected additions to family, etc.)
SECTION IV - HOUSING DATA
16. COMMUNITY HOUSING DESIRED (X as applicable) a. PURCHASE HOUSE b. PURCHASE CONDOMINIUM c. PURCHASE MOBILE HOME
d. RENT HOUSE e. RENT APARTMENT f. RENT MOBILE HOME
g. RENT MOBILE HOME SPACE h. SHARE i. RENT ROOM
j. ROOM AND BOARD k. SUBLET l. TRANSIENT
17. AMENITIES DESIRED (X as applicable. Write number in d. and e.) a. FURNISHED b. UNFURNISHED c. AIR CONDITIONING d. NO. BEDROOMS
e. NO. BATHS f. PETS (Allowed) g. OTHER (Explain)
18. DATE HOUSING NEEDED (YYMMDD) 19. PRICE RANGE (Community Housing) 20. LOCATION PREFERENCE (Community Housing) **21. REMARKS
- SIGNATURE OF APPLICANT 23. DATE SUBMITTED** (YYMMDD)
SECTION V - DISPOSITION (To be completed by the Housing Office.)
24. MILITARY HOUSING a. (^) (YYMMDD and time) APPLICATION RECEIVED b. APPLICATION EFFECTIVE (YYMMDD) c. DD FORM 1747 PROVIDED (YYMMDD) d. HOUSING AVAILABILITY indicated on DD Form 1747) (Boxes
e. APPLICANT PLACED ON WAITING LIST f. EFFECTIVE PLACEMENT (YYMMDD) g. BEDROOMS REQUIRED h. DATE UNIT ASSIGNED (YYMMDD)
SECTION VI - HOUSING REFERRAL CERTIFICATE On this date I have received a listing of the housing restrictions approved by the Installation Commander, and I will not reside in any property on the restricted list. I have been briefed on (1) the services provided by the Housing Office, (2) the DoD program on equal opportunity for military personnel in off-base housing, and (3) nondiscrimination based on physical or mental handicaps.
In addition, if any facility refuses to rent or sell to me or I have reason to believe I am being discriminated against, I will promptly notify the Housing Office.
25. SIGNATURE OF APPLICANT 26. DATE SIGNED (YYMMDD)
DD Form 1746, SEP 93 (EG) Previous editions may be used. Designed using Perform Pro, WHS/DIOR, Aug 94
APPLICATION FOR ASSIGNMENT TO HOUSING PRIVACY ACT STATEMENT AUTHORITY: PRINCIPAL PURPOSE: ROUTINE USE: DISCLOSURE:
5 USC 5911 & 5912. To identify customer needs for assistance and housing requirements. None. Voluntary; however, failure to provide the requested information will result in our inability to assist you. GENERAL INSTRUCTIONS This form provides the Housing Office with information that will be used to provide you with military and/or community housing. All items not listed are self-explanatory. SECTION I (APPLICANT INFORMATION), SECTION II (MILITARY CAREER INFORMATION), SECTION III (DEPENDENT DATA), AND SECTION VI (HOUSING DATA) are to be completed by the applicant. Information on military spouses is now being requested for Basic Allowance for Quarters (BAQ) entitlement which must be included on your Military Pay Order that is forwarded to your respective financial center.
1. TYPE SERVICE DESIRED
Military Applicants: If temporary community housing is desired while awaiting military housing, mark both boxes in Item 1, and answer all questions.
Civilian Applicants: Mark the box "Housing Referral" services in Item 1b, and answer all questions.
SECTION III - DEPENDENT DATA
15. DEPENDENTS RESIDING WITH ME a. through d. List requested data for all authorized dependents who will be residing with you. e. Provide the Housing Office with information regarding any handicapped dependent or special family health problems that might influence your preference for a particular type of housing; i.e., single level vs. two story, ramps for wheelchairs, expected additions to family, etc. SECTION IV - HOUSING DATA 16 - 21. Self-explanatory. 22. SIGNATURE The applicant must sign the DD Form 1746. 23. DATE SUBMITTED Enter the date the application was submitted to the Housing Office. SECTION V - DISPOSITION (To be completed by the Housing Office) 24. MILITARY HOUSING a. Application Received. Enter the year, month, day and time the application was received in the Housing Office. b. Application Effective. Enter the date of change of duty station (Line 14d) or other date that will be the effective (control) date. c. DD Form 1747 Provided. Enter the date that the DD Form 1747 was sent to the military applicant. d. Housing Availability. Enter the item letter for the applicable box(es) marked under Item 4 of the DD Form 1747 returned to the applicant. e. Applicant Placed on Waiting List. Enter the identification of the assignment waiting list(s) to which the applicant is placed. f. Effective Placement. The effective date and time of the applicant's placement on the list(s). g. Bedrooms Requirement. Enter the number of bedrooms required, based on dependent data in Item 15. h. Date Unit Assigned. Enter the date the unit was assigned.
SECTION I - APPLICANT INFORMATION
5. DOD COMPONENT Army, Navy, Air Force, etc. 6. ADDRESS Enter complete current address (street number and name, apartment number, city, state/country and the 9-digit ZIP code). 12. INSTALLATION/ORGANIZATION TRANSFERRED FROM Enter the name of the installation you transferred from. 13. INSTALLATION/ORGANIZATION TRANSFERRED TO Enter the name of the installation to which you are applying for housing. Include the name of the Organization/Department you will be assigned to. **SECTION II - MILITARY CAREER INFORMATION
- DATES** (Military Applications/Military Spouse Only) Enter dates in order of YYMMDD. (May 17, 1993, would be entered as 930517). a. Enter the date your current rate/rank was effective. b. Enter your active duty service computation date. c. Enter the time (in months) that you have remaining on active duty. d. Enter the effective date you were dropped from accountability at your previous duty station and gained on the rolls at your new duty station for record purposes. For overseas assignment, enter your date of departure from CONUS. e. Enter your official report date (from your PCS orders). f. Enter your estimated arrival date.
DD Form 1746, SEP 93
Registered Sex Offender Policy Prohibited Occupancy and Access to Family Housing
Specific Objective: To comply with prohibited Registered Sex Offender occupancy and access to USMC Family Housing policy stipulated in the following directives:
A. SECNAV Memo of 07 Oct 2008 -- “Policy for Sex Offender Tracking and Assignment and Access Restrictions within the Department of the Navy” B. CMC I&L Policy Letter of 31 Dec 2008 – “Registered Sex Offenders Prohibited Occupancy and Access to Marine Corps Government-Owned, Leased, or Privatized family Housing”
Disclosure Statement: Information provided is for public safety disclosure purposes in accordance with the Sex Offender Registration and Notification Act (SORNA), (P.L. 109-248), and to check names against national/ state sex offender registries.
Family Housing Applicant Action:
- Are you or any member of your family for whom you seek authorized housing under this application a sex offender as defined in the enclosure, or required to register as a sex offender? (circle one)
YES NO
Note: If you answered “Yes”, your application will be referred to the Installation Commander and Legal for processing.
- CERTIFICATION OF APPLICANT I hereby certify that my response contained herein is true and correct, and I understand that the omission of any material fact may result in denial of my application for housing, or eviction from housing if the omission is discovered after assignment.
Signature : __________________________ Date: ____________
Printed Name: ___________________________
StaO 11101.3C
- Assignment: Assignment to quarters will be made according to the following procedures:
a. Eligible personnel will be assigned to the next available set of quarters once they reach the top position on their respective waiting list. They will not be allowed to choose assignment to a particular set of quarters or housing area. If an assignment is refused, the person will be given a new control date which will be the date of refusal. Each person will be allowed only one refusal. If quarters are refused a second time, the applicant will be removed from the waiting list and will not be allowed to reapply for a six month period. When a member is offered the assignment to quarters, the offer must be accepted or declined within 72 hours otherwise the member’s control date will be changed to the date the offer was made.
c. When a member accepts assignment to family housing and then declines such assignment prior to move-in, the member’s name will be removed from the waiting list and the member may reapply after six months.
________________________________________________ ____________
Signature Date
very important
incomplete applications are terminated
after 30 days
**missing documents constitute an
incomplete application
Example of missing documents:
PG3 from your SRB or original orders •
Dependency Application (form 1751)
you may obtain these documents from IPAC
____________________________
military member signature
MCAS YUMA
FAMILY HOUSING REFERRAL SERVICES
NEW APPLICANT BRIEFING ITEM
UNEXPECTED DANGER IN YOUR HOME?
Parents Beware: The Consumer Products Safety Commission (CPSC) has identified window coverings with cords as one of the top five hidden hazards in the home. About one child a month dies becoming entangled in a window blind cord. CPSC has recalled over five million window coverings: Roman shades, rollers and roll-up blinds, vertical and horizontal blinds.
Strangulation and entanglement injuries can occur in the home anywhere a window covering with a cord is installed. Children can wrap window covering cords around their necks or can pull cords that are not clearly visible but are accessible and become entangled in the loops. These incidents happen quickly and silently. To prevent tragedies CPSC recommends the use of cordless window coverings in all homes.
Pull cords, Looped Bead Chains or Nylon Cords, Inner Cords of Roman Shades and Lifting Loops of Roll-up Blinds are all safety hazards.
CPSC offers the following safety tips to prevent deaths and injuries associated with window covering cords:
- Examine all shades and blinds in the home. Use only cordless window coverings with no accessible cords in front, side or back of blinds. Repair or replace blinds, shades and draperies manufactured before 2001 that have pull cords ending in a loop that are the cause for risk of strangulation.
- Move all cribs, beds, toys or furniture away from windows and window cords because children can climb on them and gain access to the cords.
- Make cords inaccessible. Make sure tasseled pull cords are short and continuous- loop cords are permanently anchored to the floor or wall.
- If the window shade has looped bead chains or nylon cords, install tension devices to keep the cord taut.
- Lock cords into position whenever horizontal blinds or shades are lowered, including when they come to rest on a windowsill.
Consumers can receive a free repair kit from the Window Covering Safety Council’s website at http://www.windowcoverings.org or by calling (800) 506-4636. You may also visit www.cpsc.gov to learn more about window covering safety.
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Signature Date
