MANUAL: Personnel Chapter Series CC--Commissioned Corps

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T.S. PHS-CC 294 12/20/79

MANUAL: PersonnelChapter Series CC--Commissioned Corps Personnel ManualPart 2--Commissioned Corps Personnel Administration

DEPARTMENT OF HEALTH, EDUCATION, AND WELFAREPublic Health Service

Chapter CC22--Pay and Allowance AdministrationSubchapter CC22.4--Quarters and Subsistence AllowancesPersonnel INSTRUCTION 1--Quarters and Subsistence Allowance Administration

CONTENTS

Section Subject Page

A. Purpose and Scope........................................ 4

B. Authority................................................ 4

C. General Provisions....................................... 4

D. Officers Without Dependents.............................. 4

1. Entitlements.................................. 4

2. Government Quarters - Responsibility for Assignment or Termination of Assignment....... 5

3. Computation................................... 5

4. Uninhabitable Officers Quarters Aboard Ship... 5

5. Missing Status................................ 5

6. Partial BAQ Entitlement....................... 6

7. BAQ Entitlements, Members Without Dependents Entitled to Basic Pay......................... 7

E. Officers With Dependents................................. 10

1. Entitlements.................................. 10

2. Government Quarters Assigned or Occupied...... 11

PAGE 2 PHS PERSONNEL INSTRUCTION 1 CC22.4 QUARTERS AND SUBSISTENCE



3. Quarters Designated as Inadequate Quarters.... 13

4. BAQ Entitlement for Spouses in Uniformed Services...................................... 14

5. Dependent..................................... 15

6. BAQ Entitlement, Members With Dependents During Leave, Travel Status, etc.............. 17

7. Effective Dates to Start and Stop BAQ......... 20

F. Rules for Determining Dependency and Relationship........ 24

1. Use of Rules.................................. 24

2. Lawful Spouse and Legitimate, Unmarried, Minor Children................................ 24

3. Validity of Member's Marriage................. 25

4. Child of Marriage Null in Law................. 25

5. Support of Dependent.......................... 26

6. Child Living With Former Spouse Remarried to Another Service Member..................... 28

7. Child Living With Former Spouse - Member Remarries..................................... 28

8. Illegitimate Child............................ 29

9. Adopted Child or Stepchild.................... 30

10. Dependent Child Adopted by a Third Party...... 30

11. Spouse or Child Confined in Penal or Correctional Institution...................... 31

12. Dependent Parent.............................. 31

CC22.4 QUARTERS AND SUBSISTENCE PHS PERSONNEL INSTRUCTION 1 Page 3



13. Factors Used in Parent Determinations......... 32

14. Recertification of Dependents................. 33

G. Basis for Determination of Adequacy and Assignmentof Quarters by Officer in Charge.................... 33

H. Forms to be Used to Substantiate BAQ................ 35

I. Basic Allowance for Subsistence (BAS)............... 36

EXHIBITS

1. PHS-2977 Quarters Allowance Certificate.................. 37

2. PHS-1637-1 Dependency Certificate (wife or childunder 21 years)..................................... 39

3. PHS-1637-2 Dependency Certificate (mother and/orfather)............................................. 41

4. PHS-1637-3 Parent's Dependency Affidavit................. 43

5. PHS-1637-4 Dependency Certificate (unmarried childover 21 years)...................................... 45-47

6. PHS-6070 Quarters Assignment and Termination Record...... 48



Section A. Purpose and Scope

To prescribe the circumstances under which basic allowance for quarters (BAQ) andsubsistence (BAS) are payable and to prescribe policy and procedures forassignment of officers to quarters.

Section B. Authority

The basic statutory and regulatory authority for payment of quarters andsubsistence allowances are: 10 U.S.C. 7572; 37 U.S.C. 402, 403, 551, 1009;Executive Order 11157; CC42.4, INSTRUCTION 1.

Section C. General Provisions

1. When Payable - BAQ is payable to members on active duty, according to thepay grade in which assigned for basic pay purposes, as set forth in thisissuance. All officers in grade 0-4 or higher have the option ofaccepting BAQ, or Government quarters, if available, in lieu of BAQ.These officers do not have such an option if they are assigned to aposition which has been determined as requiring occupancy of quarters toassure continuity of essential program services on a 24-hour basis or forthe protection (including maintenance) of Government property.

2. Determination of Dependency - In all cases of officers claiming BAQ fortheir parents, all waivers and determinations, including determination ofdependency and relationships, are made by the Director, CommissionedPersonnel Operations Division (CPOD), Office of Personnel Management(OPM), Office of Management (OM), Public Health Service (PHS).

3. Quarters Management and Quarters Allowance Administration - Additionalpolicies, principles, and procedures for the management of Government-controlled quarters administered by PHS are set forth in the PHS QuartersManagement Handbook dated February 1, 1978. The circumstances underwhich BAQ is payable and the policy and procedure for processing suchallowances are governed by this issuance.

4. Fraudulent Claims - Any officer who submits a claim for BAQ whichcontains false statements is subject to criminal prosecution. Inaddition, fraudulent acceptance of benefits may cause the recipient to besubject to criminal prosecution. The law provides for severe penalties,e.g., imprisonment and/or a fine.

Section D. Officers Without Dependents

1. Entitlements - Officers without dependents who are entitled to basic payare entitled to BAQ at rates prescribed (CC22.1, I3). See paragraph 7,below.



2. Government Quarters--Responsibility for Assignment or Termination ofAssignment - The officer-in-charge (OIC) or delegated official (DO)assigns and terminates quarters and also determines when quarters are"adequate" and "suitable" for assignment. Government quarters or housingfacilities under control of the uniformed services will be considered asassigned, suitable and adequate whenever occupied by a member at thepermanent station without payment of rental charges. This applies alsoto quarters furnished a member without charge:

a. By an organization or institution on behalf of the United States;or

b. By a foreign government for the member's official use; or

c. When jointly assigned to one or more single members.

3. Computation

a. Computing BAQ. BAQ is computed in the same way as basic pay.

b. BAQ for Date of Assignment or Termination of Quarters. BAQcontinues to accrue through the day before the date a member isassigned Government quarters or begins to occupy unnassignedquarters on a nonrental basis at the permanent station. BAQ beginsto accrue, normally, on the day the assignment to Governmentquarters is terminated or on the date that unassigned quarters arein fact vacated.

4. Uninhabitable Officers Quarters Aboard Ship

a. An officer, without dependents, not receiving BAQ, is entitled toreimbursement for expenses (not to exceed the applicable BAQ)incurred in obtaining quarters, when any of the persons listed inb, below, certify that:

(1) Such an officer is prevented from occupying quarters assignedaboard a ship on which the member is serving on sea dutybecause such quarters are uninhabitable due to repairs,overhaul, conversion, or other conditions; and

(2) Government quarters are not available; and

(3) The hire of quarters is not practicable.

b. The certification must be signed by the Commanding Officer of the ship or other designated competent authority.

5. Missing Status - Members without dependents carried in a missing statusare entitled to BAQ at the without dependent rate.



6. Partial BAQ Entitlement

a. A member, without dependents, who is assigned to a single-typequarters or is on field duty or sea duty, and is not entitled toreceive BAQ, is entitled to partial BAQ at the rates provided(CC22.1, I3).

b. Conditions

(1) Member, without dependents, assigned to single-type Governmentquarters at the permanent station and entitled to partial BAQ,who is subsequently sick in a hospital (no permanent change ofstation (PCS) involved), continues to be entitled to partialBAQ while hospitalized.

(2) Member, without dependents, who is offered an assignment ofGovernment quarters, or is assigned Government quarters, butelects not to occupy such quarters and resides in privatequarters at own expense, is considered assigned to Governmentquarters and not entitled to BAQ. Therefore, such member isentitled to partial BAQ.

(3) Partial BAQ is not authorized during leave en route and/ortravel time on PCS.

(4) Member married to another member, who has no dependents otherthan his or her spouse, is entitled to partial BAQ whenassigned to single-type Government quarters and not entitledto BAQ. However, such members assigned to family-type Gov-ernment quarters are not entitled to partial BAQ.

(5) A single member without dependents is not entitled to partialBAQ when assigned to family-type Government quarters.

(6) An officer on sea duty being reimbursed under paragraph 4,above, for the expense incurred for quarters when thequarters aboard ship are uninhabitable is entitled to partialBAQ.

(7) Member, without dependents, being treated at a hospital (PCSinvolved), and assigned quarters in the hospital is entitledto partial BAQ.

(8) Member married to another member, neither having other de-pendents, who is assigned to sea duty and occupies Governmentfamily quarters assigned to the spouse when vessel is in port,is considered a member without dependents assigned to quarterson the vessel and is not entitled to BAQ, but is entitled topartial BAQ.



7. BAQ Entitlements, Members Without Dependents, Entitled to Basic Pay

A B C

Member is Then: BAQ accrues BAQ does not accrue

1 assigned to a if Government quarters if member is assigned permanent or housing facilities or occupies Government station are not assigned adequate for the member’s

quarters suitable and grade (notes 4 and 5) (note 4)

2 if member is grade if officer must per- 0-4 or higher and manently occupy Govern- elects (after ment quarters because September 30, 1963) duty assignment requires not to occupy avail availability during able quarters (see normal off-duty hours Sec. C, para. 1)

3 on field duty if receving BAQ at if assigned quarters at or sea duty permanent station permanent station, or for less than and that station if reassigned PCS 3 months remains unchanged (note 1)

4 on field duty if the OIC certifies at permanent station or, for 3 months that the member was if member is not required or more required to provide to procure quarters at (note 1) quarters at own own expense, at the expense at the field field duty site duty site

5 on sea duty for any period of such for 3 months sea duty or more (note 1)

6 on authorized if receiving BAQ at if assigned quarters at Leave, accrued permanent station and permanent station or advanced permanent station (PCS) not remains unchanged involved) (note 2)

7 on excess leave for any period of time



A B C


8 sick in hos if receiving BAQ at if assigned quarters at pital, or on permanent station, permanent station sick leave and permanent from a hos station remains pital (PCS unchanged (note 2) not involved)

9 being treated if not assigned if assigned quarters in at hospital quarters the hospital TDY* (PCS is involved)

10 on TDY* (PCS if receiving BAQ at if assigned quarters at not involved), permanent station permanent station or TAD*, and permanent station including such remains unchanged duty on trans (note 3) port or under permissive orders

11 training for, if not furnished if furnished quarters attending or quarters by the Gov- by the Government, or participating ernment or by an by an agency sponsoring in Pan Am or agency sponsoring participation Olympic games, the member's or other participation international amateur sports competition 12 An officer on if not furnished if furnished quarters active duty quarters without without charge by the (physician, charge by the hospital. Such quarters nurse, other) hospital are considered furnished status at a on behalf of the United state, county, States municipal, or private hospital

hospital________________________*TDY = Temporary Duty TAD = Temporary Additional Duty



A B C


13 a student if not furnished if furnished quarters training on quarters by the by the college, univer- a fellowship, college, univer sity, or research scholarship sity, or research facility. Such quarters or grant facility are considered furnished on behalf of the United States

14 called to on date of entry on if member is assigned entry on active duty if Government quarters active duty member is not on effective date assigned Govern of entry on active duty ment quarters on that date

NOTES:

1. For the purpose of payment of BAQ under 3, 4, and 5, above, duty for aperiod of less than 3 months is not considered to be field duty or seaduty.

2. Entitlement continues during periods member may temporarily occupyGovernment housing facilities at other bases while in a leave statuswithout regard to the number of days of such occupancy.

3. Member in pay grades 0-4 or higher may elect at the beginning oftemporary duty (TDY) (no PCS involved) or temporary additional duty (TAD)not to occupy Government quarters and thus become entitled to BAQ. Formembers below pay grade 0-4, entitlement does not exist during TDY or TADif quarters are assigned or furnished at the permanent station, eventhough the quarters are vacated at the begin-ning of TDY or TAD.

4. Government quarters in fact occupied without payment of rental chargesshall be deemed to have been assigned as appropriate and adequatequarters.

5. Does not apply to temporary occupancy of Government quarters as a guestof another member for periods of 90 days or less. If a member occupiesGovernment quarters assigned to another member for a continuous period ofmore than 90 days, BAQ entitlement does not exist for any portion of suchperiod of occupancy.



Section E. Officers With Dependents

1. Entitlements

a. When Entitled to BAQ. A member with dependents who is entitled tobasic pay is entitled to BAQ at the rates prescribed for memberswith dependents when:

(1) Adequate Government quarters are not furnished for the memberand dependents without payment of rental charge.

(2) Adequate Government quarters are not furnished for the mem-ber's dependents, or dependents are prevented by competentauthority from occupying such quarters, even though quartersare assigned for the member's occupancy.

(3) Dependents are not en route or do not accompany the member tothe permanent duty station, or the vicinity thereof, so as topreclude assignment of family quarters. Under such circum-stances the mere availability of quarters which could have beenassigned does not defeat the right of a member to the basicallowance for quarters for dependents.

b. Limitation on Quarters Occupied by Member. When adequate quartersare not available for a member's dependents, the member may notoccupy, either at the permanent or TDY station, Government quar-ters which exceed the minimum standards for the member's gradewithout dependents without affecting the right to BAQ, unless theonly quarters available:

(1) Exceed the minimum standards; and

(2) Are made available for joint occupancy with other members.

c. Interim BAQ Rates. If an officer with dependents is entitled toBAQ, payment will be made at the rate for officers without depend-ents until appropriate dependency documentation has been submittedand approved. Allowable BAQ rates for officers with dependents willbe adjusted and paid retroactively to the date established fordependency or date entered on active duty, whichever is later.



2. Government Quarters Assigned or Occupied

a. Types of Government Quarters. Government quarters or housingfacilities include the following:

(1) Any sleeping accomodations or family-type housing owned orleased by the U.S. Government;

(2) Lodgings or other quarters obtained by U.S. Government con-tract;

(3) Dormitories or similar facilities operating by cost-plus-a-fixed-fee contractors;

(4) Any sleeping or housing facilities furnished by a foreigngovernment on behalf of the U.S. Government;

(5) Transient facilities such as guest houses, hostess houses, and hotel-type accommodations. (Accommodations built andoperated by nonappropriated fund activities are considered tobe rental quarters for the purpose of BAQ eligibility.)Payment of service charges for laundering of linens, jani-torial services, etc., has no effect on whether the facil-ities are considered Government quarters or housing facil-ities;

(6) Quarters in a state-owned National Guard camp. The officer incharge determines when Government quarters are adequate andappropriate for assignment.

b. Quarters Not Designated as Family-Type Quarters. A member who isneither assigned to nor occupies Government quarters is entitled to BAQ for dependents even though the dependents occupy Governmentquarters not designated as family-type quarters. Examples of suchquarters are:

(1) Dormitory quarters occupied by a members's child at a schoolfor dependents of military personnel.

(2) A hospital room occupied by a dependent under the Dependents'Medical Care Act. However, a member is not entitled to BAQwhen a sole dependent is hospitalized in a Government orcivilian hospital under the Dependents' Medical Care Act and isassigned to and occupies Government quarters (even thoughprivate quarters are maintained and occasionally occupied).



c. Quarters Furnished on Behalf of the U.S. A member is not entitledto BAQ for dependents if the member and dependents are furnishedadequate family quarters on behalf of the U.S. without rentalcharge. Examples of such quarters are:

(1) Family quarters furnished a member in an official capacity bya foreign government.

(2) Family-type quarters furnished by a state, county, municipal,or privately owned hospital to an officer serving on activeduty, e.g., as an intern or resident physician.

(3) Family-type quarters furnished by a college, university, orresearch facility as part of a fellowship, scholarship, orgrant.

d. Quarters Occupied by Dependents. A member furnished single-typequarters is not entitled to BAQ on behalf of:

(1) A spouse who is a sole dependent and who is furnished quartersin kind as a civilian employee at a Government installation.

(2) A spouse who is a sole dependent and who is furnished Govern-ment quarters while serving with the American Red Crossoverseas.

(3) A sole dependent who is a student nurse in training at aGovernmental hospital. However, BAQ is payable on behalf of adependent who is a student nurse in training at a civilianhospital.

(4) Dependents evacuated from a danger area, who occupy Govern-ment housing facilities at a safe haven.

(5) Dependents, alone or when accompanied by member, who occupyGovernment quarters assigned to another member for a con-tinuous period of more than 90 days. Under these circum-stances BAQ is not payable for any portion of the period ofoccupancy. Visits of 90 days or less may be considered socialvisits of a temporary nature, and do not cause loss of BAQ.

(6) Any dependent(s), if one or more of the member's dependentsoccupy the quarters with the member on a permanent basis or ona social visit in excess of 7 days, unless other dependents areprecluded by competent orders from residing with the member.



e. Quarters Occupied by Dependents During Member's Sea Duty or FieldDuty. A member whose dependents occupy public quarters while themember is on sea duty or field duty is entitled to BAQ for a periodnot to exceed 7 days.

f. Rental Quarters (Other than Inadequate Quarters). A member anddependents who occupy the following facilities on a rental basis areentitled to BAQ:

Any housing facilities, including trailers, underthe jurisdiction of the Government other than publicquarters constructed or designated for occupancy withoutcharge.

Rental charge refers to a charge made on account of occupancy. Itdoes not include service charges for linen, cleaning, maintenance,etc.

g. Quarters at Safe Haven Temporarily Occupied by Dependents. A memberis entitled to proper credit of BAQ for dependents when:

(1) The member's dependents occupy Government provided housing ata safe haven area after emergency evacuation from privatehousing at the permanent station; and

(2) Due to conditions beyond the member's control is required tocontinue payment of rental for the private housing in order tohouse furnishings and belongings and to have quarters availableupon return of the dependents.

(3) This entitlement will continue until such time as dependentsare authorized to return to member's permanent duty station or arrive at a designated place as contemplated by paragraphM7101, Joint Travel Regulations (JTR).

3. Quarters Designated as Inadequate Quarters

a. Entitlement to BAQ. A member with dependents may be assigneddesignated inadequate quarters on a rental basis without loss ofBAQ. This does not apply to bachelor officers quarters, visitingofficer quarters, guest houses, and similar type facilities, or toassigned quarters undergoing ordinary repairs.

b. Amount of Rent for Inadequate Quarters The establishment andadministration of rental rates will adhere to appropriate laws andregulations as implemented by PHS Quarters Management Handbook,February 1, 1978.



c. Effective Date of BAQ and Rental Charge. BAQ and rental chargebegin on the date of the member's assignment to such quarters or onthe date the determination of inadequacy is effective, whichever islater.

d. Computation of BAQ and Rental Charge. Compute BAQ and rental chargeon a 30-day month basis and prorate at one-thirtieth of the monthlyrate for each date inadequate quarters are assigned. Do not pay BAQnor charge rent for the 31st day of a month. Pay 3 days BAQ andcharge 3 days rent when inadequate quarters are assigned on the 28thday of February. Do not charge rent for the day the assignment isterminated. BAQ accrues for the day of termination if Governmentquarters are not occupied on that day.

e. Inadequate Quarters Redesignated Adequate. Rental charges and BAQcease on and after the date formerly inadequate quarters arerehabilitated and redesignated as adequate public quarters. If amember's assignment was continued during the period of rehabil-itation, the redesignation of adequacy will be made effective as ofthe first day of the month following the month in which therehabilitation was completed.

f. Husband and Wife Entitled to BAQ. When a husband and wife are bothmembers who jointly occupy inadequate family quarters on a rentalbasis, they are entitled to BAQ according to their dependent status.The rental charge for inadequate quarters will be the amount whichwould be charged for a member of the same grade who is in receipt ofBAQ on behalf of a civilian spouse. The maximum amount that may becollected will be determined on the basis of the pay grade of themember under whose eligibility inadequate quarters were assigned.Fifty percent of the rental charge will be collected from eachmember. When 50 percent of the rental charge exceeds the juniormember's BAQ, the amount collected from the senior member will beincreased to cover the excess.

4. BAQ Entitlement for Spouses in Uniformed Services

a. When family-type quarters are jointly occupied by the members,neither member is entitled to BAQ, even though the dependents do notreside in the quarters, unless dependents are prevented by ordersfrom occupying quarters.

b. When husband-wife members are stationed at the same or adjacentinstallations, both members are normally authorized BAQ at theappropriate rate when family-type quarters are not assigned, not-withstanding the availability of adequate single quarters for eitheror both members.



c. Members may be considered to be stationed at the same or adjacentstations when they are not precluded by distance from livingtogether, or they actually commute on a regular basis, regardless ofdistance.

d. When husband-wife members have no other dependents are are pre-cluded by distance from living together, they will normally betreated as members without dependents for purposes of entitlement toBAQ.

e. When husband-wife members, who are both entitled to BAQ at the sameor adjacent installation, are geographically separated by competentorders and one member remains assigned to the old duty station, thatmember will normally be authorized continuance of BAQ notwithstanding the availability of adequate single quarters forassignment to either member.

f. BAQ at the rate payable to members without dependents is authorizedduring travel status after departure from the old permanent station,or during a period of leave, delay en route, or proceed time betweenpermanent duty stations, when not in receipt of BAQ for otherdependents, and not assigned to Government quarters en route oroccupying transient type Government quarters for more than 30 daysat any one location.

g. When one member is receiving BAQ at the with dependents rate, and achild is born of the marriage, the other member may not claim that child as a dependent for BAQ entitlement at the with depend-ents rate. The child born of the marriage is automatically includedas a dependent of the member in receipt of BAQ at the withdependents rate, even though the child is not specifically claimedfor BAQ purposes.

h. A member on field or sea duty is not entitled to BAQ withoutdependents unless the field or sea duty is temporary additional dutyof less than 3 months.

5. Dependent

a. With respect to a member of a uniformed service, dependent means:

(1) Spouse;



(2) Unmarried child (including any of the following categories ofchildren if such child is in fact dependent on the member: anatural child; a step child; an adopted child; or anillegitimate child whose alleged member-father has beenjudicially decreed to be the father of the child or judiciallyordered to contribute to the child's support, or whoseparentage has been admitted in writing by the member) whoeither -

(a) Is under 21 years of age; or

(b) Is incapable of self-support because of a mental orphysical incapacity, and in fact relies on member for overone-half of dependent's support; and

(3) A parent (including a stepparent or parent by adoption, and anyperson, including a former stepparent, who has stood in locoparentis to the member at any time for a continuous period ofat least 5 years before reaching 21 years of age) who in factrelies on member for over one-half of dependent's support;however, the dependency of such a parent is determined on thebasis of an affidavit submitted by the parent and any otherevidence required under regulations.

The relationship between a stepparent and stepchild is terminated by the stepparent's divorce from the parent by blood.

b. A member is not entitled to BAQ on behalf of:

(1) A minor child (under age 21) who is entitled to basic pay as amember on active duty in any uniformed service. This includesa minor child attending one of the military service academieswhere quarters are furnished by the U.S.

(2) A spouse who is on active duty in the uniformed services of theU.S. and entitled to basic pay and allowances in own right.When both spouses are in the uniformed service and entitled tobasic pay and allowances, BAQ entitlement will be guided bythis issuance.

(3) A dependent for whom the member has been absolved of therequirement to provide support, for example, desertion withoutcause, marital infidelity.

(4) A dependent whose whereabouts is unknown and whose absence orwhereabouts remains unexplained.

(5) A former spouse to whom the member is paying alimony ordered bya divorce decree.



c. A member is entitled to BAQ on behalf of a spouse in service of aGovernment other than the U.S. This applies even though furnishedquarters or paid a monetary allowance in lieu of quarters by thatGovernment.

d. Dependency must be approved before entitlement to BAQ is authorized.After initial approval, the service will maintain adequate levels ofinternal audit to assure the legality, propriety, and correctness ofall disbursements for BAQ. (See Section F, paragraph 1a).

6. BAQ Entitlement, Members With Dependents, During Leave, Travel Status, Etc.

A B C D and member and de- and is entitled pendents occupy to BAQ at his/ transient Gov't her permanent qtrs (note 1) then BAQ If member is station entitlement

1 On duty or on Yes No continues authorized Yes continues leave (accrued, but not for advanced, or more than 72 convalescent) days at any not incident location to PCS where Govt qtrs are occupied (notes 2 and 3)

3 No does not exist. How- ever, if qtrs assignment at the permanent station is terminated at the beginning of or during leave, 1 and 2 apply on and after date of termination




4 in a duty, No exists unless travel or permanent leave status Gov't qtrs incident to are assigned PCS (includes or occupied TDY en route)

5 Yes exists but not more than 30 days at any location where transient qtrs

are occupied. (note 2 & 3).

Entitlement does not exist if permanent Gov't qtrs are also assigned or occupied. 6 On TDY or TAD Yes No continues as not incident long as to PCS permanent station remains unchanged

7 Yes continues, but not for more

than 7 days at any location

where Gov't qtrs are occupied (notes 2 & 3)




8 No does not exist ______________ 9 AWOL, not does not excused as exist unavoidable 10 absent due Yes continues to disease (as distin does not guished from exist. How- injury) from ever, if11 alcohol or No qtrs assign- drugs, causing ment at the loss of pay permanent station is terminated during member's absence, BAQ accrues on and after date of termination 12 home on PCS continues awaiting until member’s further No retirement orders in or discharge connection with physical evalua-13 tion board Yes does not proceedings exist NOTES:1. Does not apply to occupancy of Government quarters as guestof another

member by a member and dependents, or dependents alone, for periods of 90days or less. If a member and dependents, or dependents alone,occupy Government quarters assigned to another member for a continuousperiod of more than 90 days, the member is not entitled to BAQ for anyportion of such period of occupancy.



NOTES (continued)

2. BAQ credit continues if member has additional dependents whoare precluded by competent authority from occupying Governmentquarters or facilities furnished member and spouse, or spousealone, while on leave, or at a port.

3. The intent of these entitlements 2, 5 and 7 above, is that BAQcontinue for a maximum of 7 or 30 days respectively at any onelocation. Movement from one unit of transient quarters toanother unit at the same location (with or without a break inoccupancy) may not exceed the authorized 7 or 30 days withoutloss of BAQ. Occupancy of transient type quarters at differentpoints or at both the old and new permanent station, withoutloss of BAQ, is authorized for up to 7 or 30 days respectivelyat each location during any one period.

7. Effective Dates to Start and Stop BAQ

a. Date to Start BAQ--Members with Dependents

_____ A B

If member Then BAQ begins on ______________________________________________________________________

1 is called to entry on date of entry on active duty, active duty if member is not assigned Gov't qtrs for the officer

and dependents on that date ______________________________________________________________________

2 is appointed to commiss- date active duty pay begins, if ioned or warrant member is not assigned Gov't officer status qtrs for the officer and dependents on that date

______________________________________________________________________

3 occupies Gov't qtrs date of termination of assignment with dependents and unless dependents continue to occupy

quarters assignment to occupy the quarters. This is is terminated date quarters are vacated, if definite assignment is not required

______________________________________________________________________

4 occupies Gov't quarters date on which designation ofwith dependents and the inadequacy of quarters is

quarters are declared effective, if member and inadequate dependents continue to occupy such quarters

______________________________________________________________________



_____ A B

If member Then BAQ begins on ______________________________________________________________________

5 acquires a dependent date dependent is acquired, if (marriage, birth, member is not assigned Gov't adoption, etc.) qtrs for self and dependent(s) (note 1) on that date (note 2)

6 acquires a dependent date member is returned to pay while in an unauthorized status, if member is not absence status assigned Gov't qtrs for the officer and dependents on that

date (note 3)

7 claims dependent parent date determined or approved by

8 claims doubtful dependent the Director, CPOD/OPM/OM

NOTES:

1. Includes dependent acquired while member is on authorized leave.

2. a. Applies to sole dependent of officer.

b. Applies to any dependent on whose behalf a member is entitled toincreased BAQ.

c. BAQ starts with date of member's marriage even though marriageoccurs on same day as divorce from another member.

d. When blood parents of an illegitimate child marry, the child becomesa legitimate dependent for BAQ purposes.

3. If there has been any change in the status of dependents on whose behalfBAQ existed on the date an unauthorized absence commenced, a member mustreestablish his/her right to BAQ.



b. Date to Stop BAQ -- Changes in Dependency Status

A B

If the sole dependent then stop BAQ at 2400 hours (note 1) of the day

1 dies of death

2 is divorced of the final decree of divorce (note 1)

3 is a spouse in a void before date of the decree. (No able (not void) marriage payment BAQ may be made on or which is dissolved by after date of the decree, re

final annulment decree. gardless of credits accrued and not paid, BAQ paid before the date of decree may be retained) (note 2)

4 is a spouse in an before discovery of invalidity invalid (void) of the marriage. (No payment of marriage of BAQ may be made on or after date of discovery, regardless of credits accrued and not paid)

5 becomes of age (except before the child's 21st birthday a child who is incapable of self-support because of mental or physical incapacity)

6 marries (regardless of of the child's marriage. (Applies age, mental or physical even though child's marriage is incapacity) to a service member who is also entitled to BAQ on child's behalf for that date)

7 is adopted by a third before date of adoption party by interlocutory order or decree which has effected a changed

legal relationship



A B

If the sole dependent then stop BAQ at 2400 hours (note 1) of the day

8 is adopted by a third before date of adoption party and a final order or decree has been entered

9 enters military before day of entry into service service

10 is one who must be before date dependency ceases "in fact" dependent on member, and such dependency ceases

NOTES:

1. Applies also when an affinitive relationship between a member andstepchild ceases because of divorce from the child's parent.

2. Applies also when affinitive relationship between a member and stepchildceases because of annulment of marriage.

c. Date to Stop BAQ -- Other Than Changes in Dependency Status

A B

If member Then BAQ begins on

1 is furnished Gov't qtrs before day qtrs are assignedat the permanent station, (or prior to day occupancyadequate for the member begins, if definite assignment and dependents not made).

2 is furnished qtrs (cash before day qtrs are furnished.or in kind) on behalfof the U.S., adequatefor the member anddependents



A B

If member Then BAQ begins on

3 and dependents occupy before effective date ofinadequate qtrs which redesignation as adequateare rehabilitated and quarters.designated as adequatequarters.

4 is absent without of AWOL, not excused asleave unavoidable.

5 is released from of release.active duty

6 is retired before effective date of retirement.

7 dies of death.

Section F. Rules for Determining Dependency and Relationship

1. Use of Rules - This section includes rules and factors used indetermining dependency or relationship for BAQ entitlement. It is to beused:

a. By Director, CPOD, in determining dependency or relationship forthe classes of dependents or conditions listed below.

b. To guide administrative personnel in counseling members about their rights to BAQ on behalf of dependents.

2. Lawful Spouse and Legitimate, Unmarried, Minor Children - A member'slawful spouse and legitimate, unmarried, minor children are at all timesconsidered dependents for BAQ purposes, except under the conditionsindicated in subparagraph a and b below, paragraph 5 below, and paragraph5, Section E. A determination of relationship is required, but usuallya determination of dependency is not. In all instances of a memberhaving a spouse on active duty, full details must be given showing fullname, social security number, duty station, and branch of service of thatspouse.



a. Except as prescribed in subparagraph b below, either of two membersmarried to each other may claim BAQ for their adopted children orthe children born of their marriage. Such election must be agreedto by both members. If the members cannot agree as to the election,entitlement to BAQ for their children will rest with the seniormember. Entitlement may later be transferred to the other member inthe event of promotion or similar change of circumstances whichwould merit such transfer. When only a stepchild is involved,either the stepparent or the natural parent may claim that child forBAQ purposes. The stepparent must meet the requirements ofparagraph 9 below, to be entitled to BAQ on behalf of the stepchild.However, if the natural parent objects to the other member claimingthe stepchild, then BAQ entitlement rests with the natural parent.

b. When one of the two members married to each other is receiving BAQat the with dependents rate, than any child born of their presentmarriage or any child adopted during their marriage is considered tobe within the class of dependents for which the one member isalready receiving BAQ.

3. Validity of Member's Marriage - Any case where the validity of a member'smarriage is questioned is considered a case of doubtful relationship.Cases in this category include:

a. Remarriage within prohibited period following divorce.

b. Marriage by proxy.

c. Marriage by telephone.

d. Foreign nation divorce.

e. Purported marriage.

(1) Void marriage.

(2) Annulled marriage.

Submit requests for determination on validity of a marriage or forvalidation of payments to the Director, CPOD.

4. Child of Marriage Null in Law - An unmarried minor child of a cere-monial marriage null in law, or annulled as void or voidable, is aneligible dependent for BAQ purposes unless and until a court finds suchchild is illegitimate. See paragraph 8 below, concerning entitlement toBAQ for an illegitimate child.



5. Support of Dependent - Proof of support of a lawful spouse or unmarried,minor, legitimate child of such member generally is not required.However, failure to support a dependent on whose account BAQ is claimedmay result in nonentitlement to BAQ.

a. Both Parents are Members - One Parent Ordered to Pay Support forChild in Other Parent's Custody.

(1) The member paying court-ordered support is entitled to claimthe child for BAQ purposes, provided the monthly supportdecreed is equal to or greater than the difference between thatmember's "with" and "without" dependents BAQ rate. Failure topay court-ordered support in such amount will result innonentitlement to BAQ at the with dependent rate, and transferof that entitlement to the member awarded legal custody of thechild.

(2) When a member is paying court-ordered support in the amountrequired in order to claim the child for BAQ purposes, theother member having legal custody of the child is, providedfamily housing is not occupied, entitled to BAQ at the withoutdependent rate notwithstanding the availability of adequatesingle quarters for his or her occupancy.

(3) A member having legal custody of his or her child is entitledto claim that child for BAQ purposes even though the otherparent is paying court-ordered support in an amounte equal toor greater than the difference between that member's "with" and"without" dependents BAQ rates, provided that the member payingsuch court-ordered support declines to claim the child for BAQpurposes. Such entitlement on the part of the member havinglegal custody of the child exists even though the member payingcourt-ordered support is receiving BAQ on behalf of other dependents.

b. Member Absolved from Support Responsibility by Divorce Decree orCourt Order - BAQ is not payable when a member has been absolved bydivorce decree or court order from the responsibility of supportinga child or children, and the member does not contribute to theirsupport.

c. Member Refuses to Support - BAQ is not payable on behalf of adependent whom a member refuses to support.NOTE: A member does not avoid the legal responsibility to complywith a court order for support by forfeiting BAQ.



d. Divorce Decree, Legal Separation Agreement or Court Order Silenton Support or Not Stating Account of Support - A divorce decree,legal separation agreement, or court order, giving custody of amember's minor children to the spouse, which is silent on support ordoes not state that the member is required to support them, does notof itself deprive the member of BAQ for the children. This is trueregardless of the jurisdiction in which the decree, agreement ororder was issued or in which the children are domiciled. The memberis entitled to BAQ if the contribution to the support of thedependents is in the full amount of BAQ or a reasonable amountstated by or on behalf of the dependents as necessary, whichever isless, but in no case may the support be less than the differencebetween the member's applicable with and without dependents BAQrates. If the member furnishes the support specified above, themember will be deemed to have furnished support in an amount statedas adequate by or on behalf of the dependent until such time as anofficial complaint to the contrary is made by or on behalf of thedependent. If satisfactory evidence is received that the member hasnot provided the support specified above, action will be taken torecoup BAQ from the member for any period such support was notprovided.

e. Legal Separation Agreement or Court Order Stating Amount of Support - If there is a court order or legal separation agreementstating the amount of support, the member must contribute to thesupport of the dependent the amount specified therein, or the fullamount of BAQ, whichever is less, but in no case may the supportpayments be less than the difference between the applicable BAQ atthe with and without dependents rate. If satisfactory evidence isreceived that the member has not provided the support specifiedabove, action will be taken to recoup BAQ from the member for anyperiod adequate support has not been provided.

f. Settlement Agreement:

(1) Property settlements made under a court order or writtenagreement are not considered support for BAQ purposes.

(2) Payments made under a settlement in place of support areconsidered support for the period expressly provided in thewritten agreement or court order.

(3) A lump-sum settlement in place of support made under writtenagreement or court order is considered support for the periodthe lump-sum would reasonably cover support of the dependent.



g. Interlocutory Decree of Divorce - If an interlocutory decree ofdivorce does not provide for support to the spouse, the member isnot entitled to BAQ for the spouse after the date of the decreeunless proof of support is furnished.

h. Doubtful Cases - Submit any doubtful cases involving support fordetermination to Director, CPOD.

6. Child Living with Former Spouse Remarried to Another Service Member

a. If the child's stepparent is assigned public quarters and the childoccupies such quarters, determine the divorced member's entitlementto BAQ for the child as follows:

(1) The divorced member is not entitled to BAQ if assigned to oroccupying Government quarters or if on field duty (unlessrequired to procure quarters at own expense), or on sea duty.(For this purpose, duty for less than three months is not fieldor sea duty.)

(2) If the divorced member provides support as required in para-graph 5 above, the member may receive BAQ as a member withdependents for periods not assigned to or occupying Govern-ment quarters and not on field or sea duty (three months ormore) regardless of whether the child's stepparent is assigned public quarters.

b. If the child's stepparent is not assigned public quarters, but ispaid BAQ, the divorced member is entitled to BAQ on behalf of thechild, if otherwise eligible, even if assigned to or occupyingsingle-type Government quarters. However, BAQ may not be paid toboth the stepparent and natural parent at the same time for the samedependent. The natural parent has priority to BAQ if supporting thechild.

7. Child Living With Former Spouse -- Member Remarries

The provisions of subparagraph 1a(2), Section E, are not for applica-tion in the case of a member who is required to support a child in thecustody of the former spouse when the member remarries and is assigned toand occupies Government quarters with new dependents. The member is notentitled to basic allowance for quarters on behalf of the child livingwith the former spouse. This is equally applicable when, uponremarriage, the member marries a member.



8. Illegitimate Child - Public Law 93-64, July 9, 1973, amended 37 U.S.C.401 to include in the definition of a dependent, an unmarried illegiti-mate child whose alleged member-father has been judicially decreed to bethe father of the child or judicially ordered to contribute to thechild's support, or whose parentage has been admitted in writing by themember-father or mother. Such a dependent must be either under 21 yearsof age or, because of a mental or physical incapacity, incapable ofself-support and in fact dependent on the member. A member may claim onbehalf of an illegitimate child within the following guidelines:

a. General - A member who claims BAQ on behalf of an illegitimate childmust show proof of parentage. In cases involving foreign courtdecrees, parentage must also be admitted in writing and under oath.Proof of actual dependency is required in all cases and will berecertified annually. This required documentary evidence tosubstantiate that support has been provided in an amount not lessthan that specified in subparagraph b or c below. A voluntaryallotment payable to or on behalf of a child in the applicableamount is adequate evidence to show proof of intent to providecontinued support.

b. Illegitimate Child is in Custody of Another Person and Member isAssigned Single - Type Government Quarters - The member-parent mayclaim such child as a dependent if proof is shown that monthlysupport provided the child is at least equal to the applicable BAQat the with dependents rate.

c. Illegitimate Child is in Custody of Another Person and Member is NotAssigned Government Quarters - The member-parent may claim such child as a dependent if proof is shown that monthly support isprovided in an amount the greater of

(1) over one-half of the child's support, or

(2) the difference between the applicable BAQ at the with andwithout dependents rates.

In any case where (1) above exceeds the applicable BAQ at the withdependents rate, support in at least the amount of the BAQ at thewith dependents rate will be considered adequate.

d. When Both Parents Are in The Service - When both parents are membersof the uniformed services, the one having custody of theillegitimate child is the only one authorized BAQ on behalf of thatchild. If neither has custody, the member providing chief supportof the illegitimate child is considered to be the only member witha dependent for entitlement to BAQ on behalf of such child. Ineither case, the member-parent must meet the applicable guidelinesfurnished above.



e. When Illegitimate Child Adopted by Another Person - BAQ does notaccrue to the natural father or mother of an illegitimate child whensuch child has been adopted by another person.

f. When Member Marries Mother of Illegitimate Child - The member mayclaim the illegitimate child of his spouse as a dependent, althoughhe is not the father of the child. The child qualifies as adependent, in the same manner as any other stepchild, when themember has accepted full responsibility for that child by marriageto the child's mother.

9. Adopted Child or Stepchild

a. Adopted Child - A child adopted by a member is an eligible depend-ent for BAQ entitlement if a final decree of adoption has beenentered and the child is, in fact, dependent upon the member.

b. Stepchild - A stepchild is an eligible dependent for BAQ entitle-ment if the child is in fact dependent on the member. This includesan illegitimate child of the spouse, when the member is not theblood parent. See paragraph 8f above. A member is not entitled toBAQ for a stepchild if the child is receiving support from thenatural parent, who receives BAQ for the child. Astepparent-stepchild relationship ends upon divorce from the bloodparent, but not upon death of the blood parent. Hence, entitlementto BAQ for a stepchild may be established after death of the bloodparent.

c. In Fact Dependency - An adopted child or a stepchild is consideredin fact dependent if the member contributes a substantial portion ofthe child's support, and if the child's welfare would be affectedwithout this contribution. Residence in the member's household doesnot of itself establish dependency, nor is a child in fact dependentif the member's contributions merely improve the child's livingconditions.

10. Dependent Child Adopted by a Third Party

A member is not entitled to BAQ for a child after the child is adopted bya third party and final order or decree of adoption has been entered.Entitlement to BAQ continues after an interlocutory decree has beenentered if the decree does not change the legal relationship between thechild and adopting parent, and the member supports the child.



11. Spouse or Child Confined in Penal or Correctional Institution

a. BAQ Payable - Confinement of a member's lawful spouse or unmarriedminor child in a penal or correctional institution does not affectthe right to BAQ on the dependent's behalf, unless:

(1) The member refuses to support the dependent; or

(2) The member has been absolved from supporting the dependent; or

(3) The period of confinement may extend beyond five years; or

(4) The case is otherwise doubtful.

b. Doubtful Cases - Submit case involving sentence extending beyondfive years, and any other doubtful cases to the Director, CPOD, whowill request advance decision of the Comptroller General of the U.S.Do not credit BAQ pending decision.

12. Dependent Parent

a. Definition - A parent is the natural father or mother, or the fatheror mother through adoption. Also, persons who have stood "in locoparentis" to a member are considered. The term "depend-ent" as applied to father or mother means two dependents, ifapplicable.

b. Basis for Determination - Dependency of a parent is determined onthe basis of an affidavit submitted by the parent, and any otherevidence required under regulations prescribed by the Secretary.Upon receipt of the member's application, the Director, CPOD, sendsa form to the parent for completion (thus delaying final action onthe member's application). A custodian or legal guardian maycomplete the form for a mentally incompetent parent. If a parentdies before completing the affidavit, payment of BAQ is precluded.

c. Dependency Requirement - A member does not qualify for BAQ on behalfof parents because of relationship alone. The additional factor ofdependency must be met. The parents must be dependent upon themember for over one-half of their support. This means:

(1) The parent's income, not counting the member's contribution,must be less than one-half of their monthly living expenses.

(2) The member's contribution must be more than (a) the parents'income from all other sources and (b) one-half the parent'smonthly living expenses.



d. Change in Status of Dependent - A member may be paid BAQ for anyactive duty period during which dependendy of the parent is shown toexist, whether the dependency arose before or after the memberentered service. If dependency arises because of changed circumstances, and the facts show the member has started to contributeover one-half of the parents' support, BAQ is authorized from thedate the contribution began. No waiting period is required.

e. Stepparent - A stepparent-stepchild relationship ends upon divorcefrom the blood parent, but not upon death of the blood parent.Hence, BAQ entitlement because of a stepparent may be establishedafter death of the blood parent.

13. Factors Used in Parent Determinations

a. Family Unit Rule - In determining dependency of a parent, the totalincome and expenses of the family unit of which the parent is amember must be considered. Normally, the member's contribution tothe expenses of the unit must exceed one-half of the unit's totalexpenses before any one person in the unit can be considereddependent on the member. For example, a mother cannot be considereddependent if she is a member of a family unit in which her husbandis supporting himself but is not providing sufficiently for themother's individual needs.

b. Equity and Good Conscience - When application of the family unitrule results in manifest injustice, any other available evidence ofdependency is considered, and determination made according toprinciples of equity and good conscience.

c. Charity - Contributions made to parents by charitable organizationsare not considered income.

d. Parents in a Charitable Institution - Residence of a parent in acharitable institution, public or private, is not a bar toentitlement if the member claims BAQ on behalf of the parent andother conditions of entitlement are met.

e. Social Security, Unemployment Compensations, and Pensions - Paymentsmade to the parent from Social Security and unemploymentcompensation are considered income. Pensions received by the parentare also considered income.

f. Capital Assets - Unliquidated capital assets are not consideredincome, and parents are not required to deplete their capital assetsin order to establish dependency on a member for BAQ purposes.However, proceeds derived from the liquidation of capital assets areconsidered income. Amounts placed in reserve for depreciation ofproperty held for income normally are considered available forcurrent living expenses of a parent, and are, therefore, income.



g. Rate of Return Rule - In determining dependency of parents whopossess uninvested capital, compute the income return on the basisof four and one-half percent per annum.

14. Recertification of Dependents

a. All officers in receipt of BAQ with dependents are required torecertify their primary dependents at least every year. Anofficer's failure to submit appropriate documentation/forms is thebasis for administrative discontinuance of BAQ entitlement.

b. Individual officers will be notified on their "Payroll EarningsStatement" when recertification of dependent forms must be submitted. Such notification will be made during the months of Januarythrough October, corresponding to the last digit of an officer'ssocial security number (1=January, 2=February .. 0=October).

Section G. Basis for Determination of Adequacy and Assignmentof Quarters by Officer-in-Charge or Delegated Official

1. The PHS Quarters Management Handbook, February 1, 1978, includes amongother items chapters on the assignment of quarters, provision ofappliances, furniture and other household effects, quarters standards andmaintenance and repair. The remainder of this Section provides furtherdetails which may impact on quarters allowance administration and paymentof BAQ.

2. All adequate housing facilities and sleeping accommodations under thecontrol of PHS shall be considered as public quarters when occupied bycommissioned officers. Public quarters under the control of anotheruniformed service shall be those housing facilities and sleepingaccommodations designated as such by the particular service concerned.

3. Public quarters under the control of PHS shall be considered adequatebased on standards prescribing criteria for determining:

a. the basic adequacy of quarters;

b. the individual adequacy of quarters in relation to a particularcommissioned officer taking into consideration the number, ages, andsex of dependents, and grade where appropriate.

4. Public quarters under the control of a uniformed service, other than PHS,shall be determined to be adequate public quarters under standardsprescribed by that service.



5. An OIC will assign available public quarters to an officer reporting tothe station on a permanent duty assignment. See paragraph 2, Section E.

a. The OIC of a station of the Service shall first assign housingfacilities to those commissioned officers and civil serviceemployees whose duties require their living on the station. Additional quarters shall be assigned to other commissioned officers asherein provided.

b. Adequate public quarters at each station of the Service, ifavailable, shall be assigned by the appropriate official. Suchother adequate public quarters as may be available for additionalofficers on permanent duty at that station shall be assigned by theOIC, and may be assigned to other officers not on permanent duty atthat station to the extent that such quarters are available.

c. If an OIC of a station determines that quarters occupied by acommissioned officer or civil service employee are required foroccupancy by another officer, he/she may order the first officer oremployee to vacate such quarters.

d. If an officer assigned to quarters considers the quarters inadequatehe/she may appeal through channels, to the Bureau Chief exercisingjurisdiction over the station, giving in detail the reasons for suchappeal. The OIC shall forward this appeal with an endorsementsetting forth the reasons for the assignment. The decision of theBureau Chief as to the adequacy of the quarters assigned shall befinal.

e. Public quarters which are basically inadequate, or which arebasically adequate but individually inadequate for an officer anddependents, shall not normally be assigned to an officer, but anofficer may be permitted to occupy such quarters. If an officerhaving dependents declines occupancy of inadequate quarters with hisdependents, the officer may be permitted to accept assignment ofpublic quarters consisting of not more than one room and a bath.

If an officer having dependents declines occupancy of inadequatequarters with dependents but is required by the officer in charge tolive on the station, he or she shall be assigned to public quartersconsisting of not more than one room and bath, if available, or, ifnot available, to such larger public quarters as may be availableuntil such time as smaller quarters are available. If an officer,who has no dependents and for whom no adequate public quarters areavailable, is required by the OIC to live on the station, he or sheshall be assigned to any available public quarters most appropriateto his or her grade.



f. If adequate public quarters are available for assignment to anofficer with dependents but the dependents are precluded fromoccupying such quarters by orders of competent authority, theofficer in charge shall assign adequate public quarters consistingof not more than one room and a bath, if available, or, if notavailable, to such larger adequate public quarters as may beavailable until such time as smaller quarters are available.

g. An officer who is married to a person who is not a commissionedofficer shall be assigned to any available public quarters which areadequate for the officer and dependents, if any, as defined in thisissuance.

Section H. Forms To Be Used To Substantiate BAQ

1. Officers Without Dependents

a. PHS-2977 -- Quarters Allowance Certificate (Exhibit 1)

2. Officers With Dependents

a. PHS-1637-1 -- Dependency Certificate (wife or child under 21 years) (Exhibit 2)

b. PHS-1637-2 -- Dependency Certificate (mother and/or father)(Exhibit3)

c. PHS-1637-3 -- Parent's Dependency Affidavit (Exhibit 4)

d. PHS-1637-4 -- Dependency Certificate (unmarried child over 21years) (Exhibit 5)

3. Verification of Availability of Quarters

a. PHS-6070 -- Quarters Assignment and Termination Record (Exhibit 6)

4. Distribution Source for the Forms are:

a. Office of Personnel Management, Office of Management, PHS, Room 4-35, Parklawn Building - All of the above forms, except PHS 6070.

b. ASC Forms and Publication Distribution Center - All of the aboveforms, except PHS 1637-2, PHS 1637-4.

c. HEW Supply Section - Only PHS 1637-1, 1637-3, and 2977.



Section I. Basic Allowance for Subsistence (BAS)

1. Except as otherwise provided by law, officers who are entitled to basicpay are normally entitled to BAS at the rate prescribed, regardless ofgrade or dependency status.

2. BAS is in addition to overseas cost of living allowances authorized byChapter 4, Part G, Joint Travel Regulations, Volume 1, and discussed morefully in a separate issuance.

PHs PERSONNEL INSTRUCTION 1 CCZ2.4 QUARTERS AND SUBSISTENCE PAGE 37

HIS-29'77 QUARTERS ALLOWANCE CERTIFICATE * ' PHs COYISSIONED OFFICER WITHOUT DEPENDENTS

CNS ACCOUNTINS LOlNT AN0 NO.

EXHIBIT 1

U. 5. Publ ic H r o l t h Service 1 1 . I cert i fy thot the focts s t o r 4 end d ~ s c l o s e d i n th is cert i frcote ore true and correct k r the per iod sroted below:

GRADE OR R A N * WLII~AL no.

check a six-month per iod ending, June 30, 19 -, or December 31. 19 - one IC; n t h perjod ending -

2. During the per iod ~ t o t e d in i tem 1, I d i d not occupy any government quorters o r housing foci l i t ies. odequote or inodequote,

under the lur isd ic? ion o f ony o f the vnifornlcd services except for the fo l lowing periods (if nonc, so state):

ORANCW O F SCRVICC STATION

NAME o r o r r i c c n (Lost, flnc, mlddfe)

- - - - -

3. 1 funher c m r f y that my occupancy o f Government quotiers durrng the p r r rod stated i n 2, obove, wos under one of the

fol lowinp condrtions (check one):

(0) Occupied assigned odequote quor terr, for which period I wos not poid quorters ollowonces.

(b) Volunrorily occupied quarcsrs thot were determined to be "inadequate" by the Olfrcer i n charge o f c u ~ r t e r r . lor w h ~ c h

period I wor not paid quorters ollowonces.

G (c) Occupted Government quorters an 0 rent01 bosis. for which period I wos poid quorterr ol lowoncer. (A copy of the

rent01 ogrewnent wor on f i l e i n the pay r o l l office).

4. DEFINIT ION O F GOVERNMENT uUARTEfi5. The term "Government quorters," unlerx otherwise qvolrfied, n u a s ony

s l e e p i ~ accommodotrons owned or leosed by the Unrted Stotes Govrrnment, or furnished b y o foreign governmrnt efther

u d e r ogrecment wish the Uni ted Stores or on o compl imntory bosis. includrnp dorm~#orres o r similor foci l i t ies, ngordless o f

whether or not o service chorge i s mode: (Service charges mrmo l l y are to cover costs o f Iounderrny Irncn, jonitoriol

rervices, etc., ond should not bc consrdered o r rent).

- - -.---

5. Remarks

IMPORTANT ' CATk I SIGNATURE O F OFFICER h0TE.--P.nolty for pnsmt,ng folsr clorms or mokdrrg folse stoiements ,n connecr8on -0th clo~ms. F ~ n e of nor more #hen 110,000 mr rmprtsonmnr lor not more I fhan 5 yeors or both. Act of June 25, 1948, 18U.S C, a?, 1001. I i DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T.S. PHs CC 294 12/20/79

PAGE 38 PHs PERSOMJn IUSTRUCTXON 1 CC22.4 QUARTERS AND SUBSISTENCE Privacy Act Statement f o r Porn PHs-2977

&-&era Allowance Certlf i c a t s EXHIBIT 1 (Continued) PHS CoPPPdssioned Officer without Dependents

General -- This statement i s provided pursuant t o the Privacy Act of 1974 (P.L. 93-579).

Authority f o r Collection of 1nf onnation

Section b03, T i t l e 37, United Sta tes Code.

Rinc ipa l Purpose and Routine Uses

The information ca l led for by t h i s form will be used i n detennlning the extent of e l i g i b i l i t y of a coamissioned o f f i ce r f o r quarters allowances.

Except a3 indicated below, the infonnatlon you prnvl.de on t h i s form w i l l not be disclosed outside t h i s Department without your written consent:

To prospective employers o r other organizations a t the request of the iqdividual.; t o other Federal agencies i n the event of appointment of former off icers; t o Department of Defense i n event of nat ional emergency. Federal Housing Adminis- t ra t ion and Veterans Administration may obtain information i n event of employment claims and benefits. Bureau of Prisons (Departnent of Just ice) , Coast Guard (Department of Transportation), and Environmental Protection Agency may obtain copies of p e r s o ~ e l documents re la t ing t o commissioned o f f i ce r assignments t o those agencies. Records may be disclosed t o individuals and organizations deemed qualified by the Secretary to carry out specific research solely for th* purpose of carrying out such research (hS CF'R, Part Sb, Appendix B, Item 101). Disclosure may be made t o a congressional of f ice from the record of an individual i n response t o an inqu i ry from the congressional office made a t the request of t h a t individual.

I n the event of 1itigaCion where one of the pa r t i e s I s (a) the Department, any cowonent of t h e Department, o r any employee of the Department i n h i s or her o f r i c i a l capacity; (b) the United Sta tes where the Department determines t h a t the claim, if successful, Is l i k e l y to d i r ec t ly affect the operations of the Department o r any of its components; o r (e) any Department employee i n h i s o r her individual capacity where the Jus t i ce Department has agreed t o represent such employee, the Department may disclose such records as it deems desirable o r necessary t o the Department of Jus t ice t o enable t h a t Department to effect ively represent such party, provided such disclosure is compatible with the purpose f o r which the records were collected.

Effects of Nondisclosure

Disclosure of the information called fo r by t h i s form is mandatory. F d l u r e t o supply the information completely and accurately may r e s u l t i n the commissioned o f f i ce r ' s pay being held up o r incorrec t ly computed.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T.S. PHs CC 294 12/20/79

PMSI~J~-I C C 2 2 . 4 QUARTERS AND SUBSISTENCE PHS PERSONNEL IWST ( ICY. b7T) I N . PACE 39 - roam APCIOVLD IT

C O W . SLY.. U.S. DEPENDENCY CERT IFICATE

JULY XO. 1*11 , WIFE, OR CHILD UPER 21 YEARS , EXHIBIT 2

Us* r.v*.s. 1 4 r la .Y,r#mml w u r b I

l c l OLt.i*i.g "adit L h.ic al l~waacs for qranwr. prorid*d 1- an oliicer with &pnd.nt. lor the prrmd IUar a l Y / r l ftv *.nq..rt /a adwrr. d e c t r i a m dunuur to l r l

LLIIAL NO.

I I

1

uring the period s ~ a t c d I n item 1. the m a o n turned below *as my &pendent. (11 ua/. 'I mot rnd-ed a r &ep..dvmr. srarr rvsroll ol ervrrr..)

M U OF WFICLl f l u , . h r & I Y . 1 GRADE OI IlAnr

MANCN W ILRVlCL

C. S. Public l k a l t h Service

ITATlM OR WIP 111 she. 8.r. n. b-. d .d be-r ,.nt

51. adop t i r by me was for ILr d i l d 'a kaa l i t : J e cbild wma &pled by mr to marme msy ~ m o n m l a pcmia r " adraa1.6~ e ~ t k r i s J* 0.7 of iacr...r in mr

pa, or mllorsacom u mkrri..; dr child was .+( p u r a s * d d popany or iacamc mdeqaate Ior his or ha, sup~on: the dz ld r a s sot d. bamaliciary. elder dirretl, m d r o q b od18n. e i may uumt r *mute aatillie# d e child co iarom adrqwt* for h i s w her mrpport u d edwtiom; I acttmlly and nacenaarily eo.l,iktr( blun m! or. paraamml lmmds b e *nouu mho-a a b v u n t h u n b . msI*Ir IP be car.. ~ . i a ~ s a n c r . mappm. n d aImc.tim of much child.

I s Cerli f ied coun ordcr of doptian filed herer i tb or with substamietine d o c u m n u submitted:

1

PIS CAllKYL ff f ICE I U C O U ( T 1 ) l t W) ACCWNTINC *DIM1 0. YO1TR UP YEA*

n u OT rrem n * v u t LEGAL cvrram, cur rw catrmoL w CnILDicua~l t* ) 1Fn.d. r#U I . ..aluI 1 . ~ 1 1

RLLblKLmlC Df CUITDDIm 1 D C ~ b w ICHILMEm)

n a child or ch~ldwn above w r u wrre my Ieaitimmtm child or cbil&.a mo- in tbr Io(I*I ru.wdy, car. mnd control of the p n o a m - r d a h r e . I pasd h e m 1 i . l ~ ~ q u i r r d by Jr deerat: lor rb r rv .o a I * w q 8s w q l u n l b> J* I-.) 1 mctn~11~ comrobuod moothl, the .mo.mt d o r m above l r o l my arm p r s ~ m l lunds f u J. care. - im~enmc*. -upput r d mLeati lu d u i d child or c b i l h .

Did r k above-nnrd dependent run as a member of the vniformcd services a participate in full.timc training duty n i t h pay f a the period stated in 4- is-., 1 7

1 certi fy the1 the I w t a stated and d i u l c ~ e d in this cen i t i c r t r ere t n r and r o m c t ICY the pu-e of:

AmaESI

-1 OF OLF1CCR.L W N T U L I CWT*lWllW F a C* CnlLD (CnlLDaf~l

DlVClCE DECREE GRANTED BY IC.ra. I8.r.. d*r*l~

MU 0f P E R X ~ ~ FOIUEP WIFE ~ t w l l ~ ~ IF*.,,. -&I. #-,r..l, I.,,,

a

,

IYPE ff OCCREE DATE OICRtt BECWEI C I N ~ L

ZFWL ~ m ~ r r ~ c c u i o l ~

- 1 E U OF FORMER WIFE

4

5

. .

OkaimioS cndit lor hmic mllrwmnrr lr quru ra po.id.d lu mm d i i r c r rid &p.&ab a *md after IOs. -1, (a) 1-r I& iwiul r l a l r . Us. 1.) a d f b ) /OT all claims #/I.) lk mtru l c1.t-l

OAT'

I ~ i a ddici.ul +.dm di*n r -r. k y y -1 Uwrre - r ba a ~ u c k d .

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T. S. PHs CC 294 12 /20 /79

--- - . OYLS EM

Did t k .bow-named &pendent =up? ( w e m m n l qwncn or boyl ing Gc i l t t i es utukr the jw iad ic t~an of the uniformed scrvlces r i t b o u charlrexcrpt l o t br ie f v la i ts i n qwncn assigned to snotber number?

T j ~ s r n n o

Fi rat a n i f i i e t e There bar been no c h a n p i n th . a ta tw d &pendency of t k .bvc.naced &pn&,,[

EVES 0 NO amce laat cert i f icate was f i led.

Subum~imtim~ may cradiu 1- h a i r al lwsace for qusners p r i d e d for ma officer with depanbmta duisg tbe 1Use la1 ..d ( 6 ) fw a l l cIa8rs a/rrv ma11#1 c l a h j

@ATE Us' CEnTIFw*TE

I2JOwlW CCRIQ) ENOINZ SlPTEYtR P. I*,.-

UNTR PEllQ) €MDW

U.oITAMT

NO?E.-Crrlrr b r p*.*.rmu 1.1,. el--* .r r a k s r , /.Ire "-.rn. I- r.o.rau rid r h - a Pi., .I mol -r.

' rh. I lO.Dd0 .r iw.i.rl.1 ti i j -I&" J ., b t h 4 c I -1 jw 25, IUS. IS U. 1. C. 2t7. 1001.

I 1 .ill iu*diat. ly aotify n. p.yr*ll dl ir. J r)r chas~c ir t k .bore-statd depmlearr.

DATE

- . - . . . .

LLNAlURf 01 WIICLR

- - . . . . . - .

. * . I

PAGE 40 PHs PERSONNEL INSTRUCTION 1 CC 22.4 QUARTERS AND SUBSISTENCE

EXHIBIT 2 (Conti.nued\

1'riv;tc). Act ~ l n l c ~ r ~ c n t for For111 I'HS 1637-1 L)cpendcncg Ccrrific:trc (\\.ilc, or Child ulrdrr 7-1 Yc.cr\i

General

This stntrmcnt is providrd purslt;lnt to t h ~ : I'rivncy Act 01 197.1 (!'.I,. 9: 5 7 1 ) )

Authority for Collection of In/orn~otiorl

T l ~ c Dcpcndcntr Assistance Act of 1950 (10 U.S.C. ltr71 rr . SC~, )

Prirrcipal P U ~ ~ O I C J and Rout i~t r U I ~ J

T h r information sul~plirtl on thcsr forms w-ill bc u ~ d i r l dc~rrtxtinirl~ \\h.~t as\is~ancr Inav Irgall! IIC p ~ o \ i d r d for drpcndcnts of con~~nissioncd oficcrs under the authorizing st:ltut~

Exccpi as intlirntrd bclow, thc information )ou providc o ~ r tlrir fottlt \,ill I ILSI I J C ~!l.clvscd clui,idc this Dcl)nl~r~lcrrt without )our wri t~cn consent:

T o prospccti\.c rmplo!-rrs or othrr orp;1ni7:1tions a t t h ~ ncli~n.*t tbf I ~ I P i~~t l i \ ic lu :~l : 11, o111t.r Fr.tI0-r.rl act.riclt-r i n it,:. cvcnl I J ~ :11>1)oi111111~~1tt of forrnvr 0 f i c t . r~ : to l > c ] > ~ r t n ~ c t ~ l I)! Do.f~'~ii*' ~ I I t s \ , I I I 1 4 rla~i~ttr,iI C I I I ~ ~ ~ ~ , , I I C ! f j t i r t . ~ ~ ~ of l J t iw~>s (rJt.p:+rizttt,nt or Justice), C:o:t\t.Gun~d ( D ~ ~ ~ J . I I ~ I I I ~ ~ ~ ~ ~ uf 'J : I I I ~ J I I ~ ~ I I I I I ~ I I I ~ I ~ I : I ~ 1'1~n1a.t ti011 :\I:*.III, I?I.-\ ol)tair\ col)irs of pr.rsollnrl durul~~l~rr ts rl.l;~titia to cot~tr~tirsior~rcl of11c1.1. ; ~ s s i ~ ~ l r n ~ . ~ r t > to thorc agt.riri*:i. Rccortl~ ma.: Ilc cJist~Io**~d to i ~ ~ c t ~ ~ i t l u a l s an11 u i ~ : ~ ~ r i ~ ~ t i o ~ ~ s ~le~c*rii~vl q ~ ~ : t I i l i ~ ~ ~ i I>. 111s. S : C ~ ~ . ! , I I \ 14) c.3r1) ~ J V I I :prc.iitt I ~ - \ ~ : ~ I ~ I I I st>!< l v f e ~ r

tilt- l j ~ ~ r p o s ( ~ of carryit~q out strch r1.srarc11 (45 C:IiR. l'.~rt 51). :\1)11t x1<11\ l i . 111 111 itjl ' 0 , I I I s c I ~ ~ ~ I I I ~ I I I . I~ . 11,. I J I ~ ( ! P ~ t )

co~~jirc~rsio~tal trfic.c frur11 thc rtxord of 311 itidividucll in rc>lKblbbc \(I . I ~ I iricluir) frrnrn 111c cong~cssion;rl oflrr c rx1.1tlr .11 thc nyucst of that intlividual.

111 tltc C\.CIII of i i t igil t io~~ whcrr OIW of the p;triirs is ( a ) 111t. I . > t ~ l ~ a r t t ~ x ~ ~ l t . i n v C ~ I I I ~ ~ ~ I I ~ ~ I I I of tht, P*~p:irirlte 111. cr ; I I I \

crnolo).rc of tllc. Dcoarirt~cnt in Ilis or 1lc.r ~~ll:c.i;il crprrcit{: (1) 1 tht. i'nitt.tl St;ttcs \ \ . I I~II . I > c . ~ ~ ; i r t ~ ~ i r r ~ t 11, 1. 1 1 r l i r 1 < s tltat tllc vI;\irtt. if s t t c ~ ~ ~ s l t ~ l , is likelv to t l i~~*ct ly i ~ ! T v t t t i l t , I . I I ~ I I I I S t t f I ~ I . I), l).brtr,~t.l~t r>r ~ I I I , . 1 s f it; ~ . L * I : Z I I ~ X I ~ I I ~ . .

or ( c ) nrly D:*paril~tvnt c t~ tp loyc~ in his or Ircr itttli\idual cal~;~eity \,III.I-c ittc Jt~sticc* U r p ; ~ t t r ~ t ~ * ~ i t 1 1 ~ s acrv.r.d 111

r~ - ) r r t . s r~~~ t surh P I I ~ ) ) \ I > ~ I . ~ , 01r ~ ) C / ) : I ~ ~ I I I I ~ I I I 111.1). iiiscl<>st. auc.)r I:, c c , ~ c l \ :IS i~ rl~.~.~rrr 11~~1r.il)la. c,r I I ~ I . . , \ . I I ~ I I I i!.,. ! l t ;).it:. I I I ~ I I L 1 4 Jtrsiicq. 11) 1-11aIj1r tllnt D I * ~ : I ~ I I I I ~ . I I I 141 t.fr*.r~i\t.li V C ~ I J Y , . I - I , ~ 11 , , . II \Y, ~ x , I v ~ \ I . ~ star11 I I W IO,,III<. i. ,. - I I I J J . ~ I I ~ + ~ ~

with thc yurl,osc lor whicll 111c rccvrds wcrc collccicd.

E ~ e c l s 01 Nondisclosure

Disclusttrr ul tllr ir~forlllatian rallcd for 1jv ~ ~ I I . S I . f u r t ~ ~ i is \ L ~ I I I I I I : I I \ : ~IIJ \ \" \ . ( . I ' , f ~ i l i ~ l t . to S U ~ I J ) ~ ~ ,111 1111. i i ~ f v ~ ~ ~ ; a f i r > ~ l will preclude ~>r-otcszi~rq of any assistance bt.ltcfi~s for 111t. cll.\tvutl* ilr:ulrr~i.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T.S. p~s -cc 294 1 2 / 2 ' -

. . . . .

PHs 1637-2 ,. PHS PERSONNEL INSTRUCTION I CC 22.4 QUARTERS AND SUBSISTENCE PAGE 41 (Rev. 9 / 7 7 )

DEPENDENCY CERTIFICATE fO(lY ACCnWLD BY COUP. GEN.. U.S.

JULY 8. a#*( MOTHER AND/OR FATHER'

Ceetiht* d 016-

U. S. Public Hulth Service 1

M-MUIORUC~WWO

EXHIBIT 3

1

2

I I I I

NO. NAW a anarr UA&M .l&) O W OI) RANK

3

&

Icqril IL . t . thek toa ta td u d ~ b & i s ~ ~ ~ d u r r r t l r C k ~ e . I . ~ a e b t ~ o ~ ) ~ ~ . 1 1 . ~ . 0 ~ 1 f - q m u t a r I r n J . l f o o u . b r r ~ d - r ul &cr

4

b Tbe t a a l income of u i d dcpdcnr(r) fmm all aoucu, inchadin but not restricted to r a m -penu.tion. rionr, annuitka, alimony, ntirmsmt bcpcbtr, and the mloaabE v a k of gifu and armtnbu-r received ci others but ~ l u d i m ~ my lifts m d mtnbutionr m not more than

D"n

r

Ovn O w

9

Isian the above-named depmdmt(s) occupying Corcrnment pruners or bowing facilities under ilw jurisdiction of the uniformed wrvices without chary?

pd t k .above-na+ dependent(!) occupy Gwarnment q u r F r or e u n facilities u d n tbe yrwd~ctmn of the un*amed rmo. n h t &arb at any ~IOK me & &U ipdU in tun I above?

0 0 t l . . ~ i s m* h t r / r ~ h t ~ p s r dr l i r c L i d I I

~ e ~ ~ a ) d k l . r i r / ~ e u ( . c t ~ ~ o o r r f . r . r e r W d L i . ~ / t ~ n ~ :

.urn i s .m&t. uftk ~W,.JW &US)

vuou 10

I 9 did did wc claim the a h u n e d dtpndcot(s) a8 uanp tion r) on my Federal 1-me Tu return for the put akndar p r filed with the

I

7

'T'his form. offar proper nedilrcotfion, shall olso be ur-d in thr to.* of o d*p.d*r* husbmnd. (I" Eshibit PUS 3-13&008. HEW P A Y R O L L MANUAL.)

DEPARTHENT OF HEALTH, EDUCATION, AND WELFARE ' I S PHS-CC 294 12/20/79

-ME VGS, mi&# mirid, Ian)

-* OF l*".U (WUIUL AT

Tbe -Me taJ m u k a d u e 04 a11 income-producin~ propcny (kldisg -1 uurc, cub .r knl rr*d in rbr krl. U C W I I N ~ rtc.) o w o d by the d o n - m m d dcpcodcot(s) is oat more rhrn

- - - -. - - - -

Thc total of my conrributionr made l d e l y toward the wid actual Evin a p n w s of th: above-namcd dc ndcnt(e (iddiq 1 ruk n - i ~ ~ ~ l d Or rr-I nh 0, d iw r d u -1 a d d r i r ~ , /mi*& by d is not kar than 1.

8

8

I - Such contributions arc made by me (0 the arid &pndent(s) without any ronsidrratiwr in mturn tberrfor

Additional material fa& or aplrrutPor (11 IM J ~ W ir wrd. u r r - ~ l

AWACI M R O C U ( ~ ~ -TI-IC

PAGE-42' PHS-'PERSONNEL INSTRUCTION 1 C C 2 2 . 4 QUARTERS AND SUBSISTENCE

EXHIBIT 3 (Continued)

Privacy Act Statement for

Form PHs 1637-2 Dependency Certificate (Mother andlor Father)

General

This statement is provided pursuant to the hivacy Act of 1974 (P.L. 93-579)

Authority for CoUcction of Information

The Dependents Assistance Act of 1950 (10 V.S.C. 1071 et. rcq.)

Rincipal Putposes and Routine Uus

The information supplied on these forms will be used in determining what a u i r t m a may legally be provided for dependents of commissioned o f f ~ e r r under the authorizing statue.

Except as indicated below, the information you provide on thk form will not be disclosed outside this Department without your written conmt:

To prospective employen or other or8anizations at the request of the individual; to other Federal agencies in the event of appointment of former officers; to Department of Defense in event of national unersency. Bumu of Prisons (Department of Justice) , Coast Guard (Department of Trmrpoxtation). and EnvironmenW Protection Agency may obtain copies of personnel documents relating to commissioned officer assignments to those mgencies. Records may be disclosed to individuals and oxgnizations deemed qualified by the Secretary to carry out specific research solely for the purpose of cury*bg out such research (45 CFR, Par1 Sb. Appendix B, Item 101). Dirclosure may be made to a congessionrl office from the record of an individual in response to an inquky from the congressional office made at the rquest of that individual.

In the event of litigation where one of the parties is (a) the Department, any component of the Department. or any employee of the Department in his or her ofiicial capacity; (b) the United States where the Deputment determines that the claim, if succeuful, is likely to directly affect the operations of the Department or any of its components; or (c) any Department employee in his or her individual capacity where the Justice Department has agreed to represent such employee, the Department may disclose such records as it deems derirable or necessary to the Department of Justice to enable that Department to effectively represent such party. provided such disclosure is compatible with the purpose for which the records were collected.

Effects of Nondisclosure

Disclosure of the information called for by the% forms is voluntary; however, failure to supply all the information will preclude processing of any assistance benefits for the dependents involved.

r w s - m - r CC2 2.4 QUARTERS AND SUBSISTENCE a , Z @ @ N N E L INSTRUCTION 1 PAGE ,u,,,ED

I t v . .-ID HE&LTM. EDUCATION. AWD WELFARE uac€r W L W W.YRS11 CWLIC WLLTW mnnm

1 1 BRuKn YRVKE

U. S. Pllblic Health Sen i fe I

I I I (No(*.-VCn his .~pbcwim is br w pmr alp < k c 4 J* followy as st opplr*~)

STATWI( DI WW m E U Ill a h . F'w. n.. brr ~ d . &*.a. . r U

2

1

Idarmtion Relative My/Our K k p d e s y Cpon Officer Named Above

I

MIL OF BIRTH

i

4

5

6

My cbildrra f ia r ld iag adaptrd mnd sr*~cb~ldvrn) ww sentog l a Qe Unifumd Service8 of tk Unlud Stater:

ADMEU DATE Q WITH

NAME OF MFKLRS FATUCR

- - -

I/IYe Odd Odid not f i le 8 federal incorn lu MlUrD f a PSI cnlemi8r or fiscal Year. I f l8X MUCn w u filed, i t was f i k d wi~bCdlector o l Internal Re*rnre at (cur *ad ~ u c r n l :

0 PRESENT OCCUPATION OR IUIWSS QFCf I.$ *ATHER *U AND ADMESS 06 CYLOYCI (I{ rr-lnd. nure -"J

b

- - - - - - -

List el l red u u t e d pmonal property, i r ludirq cash. acockr, bond., eu: . o r n d by you a d pu b d n d (0. ui/.J. Do rot ~nc i rd r [ u a ~ c n r sr boam*bold *qr~pmrnrrJ ---

DEKRPTIM - I Y A M Y*TGltLS. LKMS. ETC. Tl(ElEW I

*IYt Of 0PP)tLI'IYrmLI

*DDlf U

If y w d o n a mainlain your own bowbold . g i n tk follmrin6 information &OUI prcw wirb wbm p u live:

- -

I gLy

b ~ , * ~ ~ r l ~ . ~ ) r . W l J r k d * & ~ . - d ~ ~ . - . O ~ L * ~ ~ H ? ~ ~ I ~ V ~ I E . ? A I M U W U * L ~

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T.S. PHS/CC 294 12/20/79

)UYL AWD *DDILII

?mLEm OCQHATKII m B U U L S OF MFKER'J YITHER YUlE AND ADOIEU W WLOICR t l l m - ~ l m l . .u. m r . 1

RELATOUWIP Y1ITrnV PAVUl!N? FOI lOQl A w ULUS

i

. - --.. -- 4 - PAGE 44 PHs PERSONNEL INSTRUCTION 1 CC22.4 QUARTERS AND SUBSISTENCE .

- ---- -- - EXHIBIT 4 (Continued )

*CR€LCNT TOTAL K Q l E S M C E OF INCWL -ICE Of =a W K L T ?011 T M

K O * PASl V I M

I I U.S. tovt. au ia l mrcmrity p q r a u fOlC ------- .-- - A t e '.I Smiwvr hruwmra) T-I-i

.--- I

! ':.'a: nl i.am, pro lvcr i ,- - -- - . . - . . - . - - - .

I Other iacmmr (Sper~/ll . - . -- - - --

I 1

1'; I :t..n&,,. bow a t x l n 4 c : ,-- --,..---- - -~(lr TOTAL EXPENSES I PWSEWT TOTAL EXPENSES t l iu / YONIHLI t 0 0 THE ITSY Y(IWIULY f OR THE . . --

I I LICENSES I PAST Y E A R I I EICLNGS I P A ~ ~ E L * +- - - .- - -. - - 8 R;rt r- c - - - - - - -- - - - . -- . - - . -- -- - ! PI. I. "I., w h u,.

- .V.dr. Pcndlry /w prr6r*r,ac l.lrv rL8-s o u k m g /a/%.. sIalrarmr# i m rmnrurtton r i t b c1.t-r: Fame 01 no1 m a . ILI 1IO.OW or i - p n s o w w u (r .oc ro r r I&" 7

).#rr, ur both. ( A r r o/ /an. 2 j . I Y J R . 1 4 U I. C. 287. 1001) - --..- --. - I,We *ill wt i l y tltr P u L l i ~ l l r s l t l ~ %.trice at orce ol any c h & r i n my/our fi~libncial circun btanie3 or cham@ in dependency oa the ofricer

I,,\Vr hercLy swrar (or affira) that a l l thc fore6mn~ atatelacnts u c true and c m c c t and that cacn wren1 for ~ h a . i n c r e e d allowances are claimed becmurc of J*pnJt nry ir in 1 . ~ 1 dtprnder.~, to the &.yce inJicotrd, upon t L : officer for ryyxni. I/Wr lurther .war (n aIf tm) that I / r e bwe rcaJ the penalty p w i r i o n s .Lour t r~ncrrnir~g the pn-.r-min~ 01 IJse c l a i m and the mahilrg of false statements i n connrctlon with claims

Fam w bu~imess oprretim~ espcu.

&her sxpemmr* IS).cifyl

I

. - L

L - -- - - -. - I I

Co:.,,\) ,< - .. - -- - -- . - -- - , omi Slulr (or I ~ t r i l u r ~ ) o l - ----

- . ..~

13 1 S l w w &owe-named ofricer's m n ~ h l y contr ibul~ws .o you. ~ncludrng hrs room and board, i f any, d u r i y the pas1 year. C h c k ;a *X. column ewh ~ o n l h that offirer l i v rd i n )our household . ,7T. - - - - - -. - - - - - . - - t UIHTt t At12 * t A P

-- -.- -- 1 -

I

--

. - -- (MI.")

I

I

DEPARTMENT OF HEALTH ,-EDUCATION, AND WELFARE T . S . PHS-CC 294 12/20/ 79

1 C I ~ l i ~ i , ~ ~ I !

-. -.- -~ .- . ----- -.

Utdirac~ It1.0,t. Is#ht, #us. w~rdrJ -

\t=dac .

-'I- -- -- -.-

C C 2 2 . 4 QUARTERS AND SUBSISTENCE P H s PERSONNEL INSTRUCTION 1 PAGE 45 )tS. I4114 REV. 9 . 1 1 DEPENDENCY CERTIFICATE m s rcuw~r~w mlwr AND NO. I.3." U I O Y C O .v

EXHIBIT 5

CMDL 01 l U W K

. -. . .- . -. . . . - - - - - . COLIC. OEM.. U.S.

JULY IO. 1931 UNMARRIED CHtLD OVER 21 YEARS -

Pair I--CerciCcrfc of 0 6 c e r

1 I

URUL NO.

~RAMCH OF SERVICE

U. S. Public Health Service

(Uw bmh (.) IU I& i m i d rlaim. U J ~ (a) 411 (W jr all tlaimr JIII L(r i m i d <him) I

MAMC Ot WPlCCl (h1.fid. m a )

- STATION OR SHIP ( I l r A i p , :w new, bbmr w4 s.1 k r ma)

b

1 (u,, (8) .ad (b) fw ail tl*imr #/I- I A ~ initid 6 h “ ) ] U - MONTH PERIOD LNOINO

1 I certify that the facts suced aod disclosed in this cenibcate (Prrt I) are true and correct fo r the purpose of:

I Obtaining credit for bnsicaHowancc lor quarterr'provided for an officcr with depcndcntr on and aftcr. DAIC

c

2

Substantiating any credits for batic allowance for quarters provided for an o%cer r i c h dependents during the

(UJS * d y (r)fer t ~ t o ~ ~ ~ f w d u w r d,tirw. r dnmmimahmi

D u r i n s the per iod stated in i tem 1, m ch i ld (w~wedbrl~w) was unmarried; was 0 physically incnprcitaced 0 meorally defec- five m an extent wh ich rendered bimJher incapsble o f sctf.suppon and war. berefore, i o (act depeodcnt om me l o r over half of b is jher ruppon.

I I

l a - w o w t ~ rsntoo SUOINS sr.rcwmcn so. Ir-

Obtaining crrdit for basic allowance lor quartera provided for an oficer with depcndcnu h r the period

3

4

5

6

7

fRoM TO

8

I I - I Doit of 1611 crrlihcau, ar i j h i r u rhr brrr crrr*car Nrd, J.u rr Ira11 3 waamthr prior m I n k of rxtrurion o j t h i ~ ctriiJcar

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE T.S. PHs-CC 294 12/20/79

T b e above-named dependent d i d n o t occ'upy Go*ernment quarters o r housing fsciliries under (he jur irdicrion o f the uniformed serv ico wirhout c h a r l e fo r abc per iod stared in i tem I

I s Such contributions wcrc ~nrdc by me to rhc said drpcndcnt without any considcrrtion in rcturcr thercfor

Additional rcmarkg. k c t r or cxphnaiions such a8 type of il,ciprcitation, prior period of ruch incapacitation. etc. tl/rr., .Mr. t :vs.*rd. 1,.

rwamran.. r m r r w l

IMPORTANT Notr -?r.abv for p r ~ e m * . / d , r r(.sm> w 1d11t . ,,.".,,I ' f ' , ; 4 ,

84.. r l ' . d v mruanmrrc /or m a m n r ah.. S p.rr r krh. 4 J D U N. JW8. I1 U.S.C. 117. 1001.

r

b

I

L ~ S A C I YOUTMLT ~WOVLI - s

1

The reasonable total mr rkc r value of a11 income-producing property (inclndinr rrrl crlrrrr. car6 oar hwd a d in tbr bur#&, nrnririra efr.) owned by rbe above-named dependem d u r i n l the per iod srar:d in item .6r was aor more rbao

a

b

I rill irnmrd~nalr nooh mz parroll o6ce of sny cbmso m rhc 8borr stated dependmcr

1 0 did did not claim thc above-named dependeat re r dependent on my Federal racomc tax return for tlw past crlcndar year filed with the

MTc(J*U nrfi4cdi*m'

COCuCTOR OF IurruNAL IlimNUc AT (Ad'r'~r)

The total d my contribu~ions nrade tukl) to\-ard thc raid actual living erpcllscs 01 the abovc-nrnbcd dcpcl~dcr~~ (inrludinl al l r o ~ h conuiburionr and Ik rraronablr wlur o/ aL' urar i u k ar quardrr, and r v b r u ~ n r r j u r n i ~ k d by nu) during the period naccd in item & war not less thrn

Actual tw11r1 living crpcnres of the abovcnamed $&cndenr ( iadud in~ rh rraroncrbl w!ur of quarurr, rubri~lrnrr, rK.. j u r n u k d by mr) dur- 1n6 the period

*IGNAT"M of. w*l=R

R U S W DCUNDSNT WAC NOT C U l M C D

The total incomc of!aid Jrpcndcnt iron1 all rourccr, includinp, hut not restricted to, reccipts frbm trust funds, warzs. compenuoon, penstons, annutt:er, retirement benefits. and the reasonable value of gilt8 and coc~tributionr, rcceivcd from others butmrludint my gifts and contributions during thc p c r i d strrcd in i ~ c m 6, war not more thrn

FROM' TO (Dm o j ~ h i r rn,@r*r) Wcrc not lets than

PAGE 46 PHs PERSONNEL INSTRUCTION 1 C C 2 2 . 4 QUARTERS AND SUBSXSTENCE

- Pur I l - C c n i b c a t e ol - Physician T 5 (Continu& 1 1 certify chat I am a d u i y + ~ f i m r d physician entitled to nractirr *~edi i in . under d

b c

I I I I

d

c

j

the law of >,'

That 1 am a medical officer in n rnwr n ruw 0 ran FORCE 0 WILK rurrk s r ~ v a u 0 orwcm [Sprilr)

1 I I R n 111--Ccnif iare ol Curtodim of Child, if Other Tho 0 6 c c r

That I aacndcd the patient named below over a pcriod of a p p r o ~ i m r t e l ~ N A M E OF CAllLYf (f"n. aiUlr i m i i d . /ad)

Tbat I lrrt examined the abovcnamed patient on

T h t in my opinioli mid patient wan ineapabk of aelkuppor; b r u u u of k i n g

0 YCWlAUY DCFECIIVE 0 ?W*SlCAUY II(CI?ACITATED O V U THE Q TWI

1

2

OATS

. a a ~ o o ~ CWY TO

DATE

VC**S

That in my opinion arid incapacity is (J ~RMAMFMT U TCMFORARY

'The term "Depndcnt." as drhued in section 102 of the Grccr Cornpentation Act of 1949, includcr an unmarried child of a nlember ol the uniformed n n r i c c ~ who i r over 21 cars of age, incapable of ~ e l f - ~ u p p r t btraurc of being mencrlly defcctirc or physically incapacitated, and in fact dcpcndant on such member L r ovrr half of his or her support

I hereby certify tbal the follow in^ statements are true

AOO~CIS

IIONIHS

.IONATURL oc MYSIC~AN

d

WEUS

I rcccivcd A*"* FROM nr

s YOltTM

b

$

*mu€ or o r r l c c ~ /&#,GII. lild/rl

THC AMWYI WAS RLYITTCD .Y

0 WMSOYAL C M ~ C K IZ] DANK DRAV [7 MOPICY ORMR D WLL WTE a ALLOTY~NT 0 O T H E ~ ( ~ , ~ i / y )

Thc amount remitted war ncccuary for th'r support of - N A U C O C D U C N O E M WILD fF"rr. aiUh imirs.1. Ian1

-ID REMITTANCE a WAS U WAS IYIT USED W L V MI THAT NRIOSC

T b c actual p r r o n r l living cxpcnrcs of said dependent during the

INPORTANT

80 T E . - I ' d 9 {u wrr,mlirt /ah8 r l a i u or -4bi-I /aLt nwmrmtr i. rn-rrrno. ruA r l a t u : Far* 4 .DI r u e lha.

r im u n m n r w war m r r #be* 5 yrar r huh. . ~ a JU*, ~ I W , . 6. s. c. m. IW,.

OATF SIGRATUIIL OF CUSTOOI&N

' CERIO~ * Were not less than

rnow rnucr -LT rrcun

s TO

CC22.4 QUARTERS MJD SUBSISTENCE PUS PERSOHNEL INSTRUCTION 1 PAGE 47 . . ..-,- .- . . . . . .

EXHIBIT 5 (Continued)

Privacy Act Statement for

Form PHs 10374 Dependency Certificate (Unmarried Child over 21 Years)

. .

General

This statement is provided pursuant to the Privacy Act of 1974 (P.L. 93-579)

Authority for Collection of Information

The Dependents Assistance Act of 1950 (10 U.S.C. 1071 et. seq.)

Principal Purposes and Routine User

The information supplied on these forms will be used in determining what asistance may legally be provided for dependents of commissioned officers under the authorizing statute.

Except as indicated below, the information you provide on this form will not be disclosed outside this Department without your written consent:

To prospective employers or other organizations at the request of the individual; to other Federal agencies in the event of appointment of former officers; to Department of Defense in event of national emergency. Bureau of Prisons tDepartment of Justice), Coast Guard (Depart. ment of Transportation), and Environmental ~ r o t e c t i ~ n Agency may obtain copies of personnel documents relating to commissioned officer assignments to those agencies. Records may be disclosed to individuals and organizations deemed qualified by tht Secretary to carry out specific research solely for the purpose of carrying out such research (45 CFR, Part Sb, Appen- dix B, Item 101). Disclosure may be made to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that

individual.

In the event of litigation where one of the parties i s (a) the Department, any component of the Department, or any employee of the Department in his or her official capacity; (b) the United States where he Department determines that the claim, if successful, i s likely to directly affect the operations of the Department or any of i t s components; or (c) rny Department employee in his or her individual capacity where the Justice Department has agreed to represent such employee, the Department may disclose such records as it deems desirable or necessary to the Oepartment of Justice to enable that Department to effectively represent such party, provided such disclosure is compatible with the purpose for which the records were collected.

Effects of Nondisclorure a I

'~

Disclosure of the information called for. by these forms i s voluntary; however, failure to supply all the information '

will preclude processing of any auistrnce benefits for the dependents involved.

DEPARTHENT OF HEALTH, EDUCATION, AND WELFARE T.S. PHS-CC 294 12/20/79

r .nn 1.0 m n /. nT1ARTERS AND SUBSISTENCE PHs PERSONNEL INSTRUCTION 1

DtiEW-PHs- STATION: , STATE: OCCUPANT NAME: GRADE/RANK: SOC. SEC. NO: - - - EFFECTIVE DATE: ASSIGNMENT-PERM TEMP LOCAL HI R E - Y E S N O - RENTAL DATA:

BASIC MONTHLY RATE: ADJUSTMENTS: ADJUSTED BASlC RATE : -- . -

ELECTRIC: WATER: GAS: FUEL: GARBAGE: -.

SEWER. OTHER: TOTAL UTILITIES: FURNISHINGS: - - NET MONTHLY RENTAL RATE: 81-WEEKLY NET RENTAL RATE:

QUARTERS DATA:

BLDG NO. QTRS NO. HSK NONHSK S U B S T A N D A R D - Y E S NO- INADEQUATE-Y E S N O NO. ROOMS NO. BEDROOMS NET SOUARE FEET-

FURNISHINGS DATA:

ITEM: SERIAL NO: INDEX NO:- IT EM:- SERIAL NO: INDEX NO: . . . . ..

ITEM: SERIAL NO: -INDEX N O : - . ITEM:- SERIAL NO: -INDEX NO.- ITEM: SERIAL NO: INDEX N O : . .

I AGREE TO OCCUPY GOVERNMENT QUARTERS I N ACCORDANCE WITH PUBLISHED POLlClES AND PROCEDURES ACCEPT RESPONSIBILITY FOR FURNISHINGS LISTED. MY SIGNATURE BELOW INDICATES ACCEPTANCE OF THE QUART F UNDER THESE TERMS:

- - . SIGNATURE OF HOUSING OFFICER DATE SIGNATURE OF OCCUPANT DATE

BLDG NO: OTRS NO: OCCUPANT:

PHs-6070 QUARTERS ASSIGNMENT & TERMINATION RECORD (7.77) B. TERMINATION

DHEW-PHs-

STATION:

STATE :

OCCUPANT NAME:

.WC. SEC. NO:

EFF-EC.i:VE DATE:

01-WEEKLY /MONTHLY NET RENTAL RATE:

BLDG FtO.:

OTRS NO.:

EXCEPTIONS. ------- .--

- -- - -- - -

I CERTIFY THAT THE ABOVE NAMED OCCUPANT HAS BEEN CLEARED OF QUARTERS AND RELIEVJ; OF RESPONSIBILITY EXCEPT ASNOTED UNDER EXCEPTIONS:

"

- SIGNATURE OF OCCUPANT DATE SIGNATURE OF ~ ~ ~ S I N E P f f d ~ i j ~ DATE DEPARTHENT OF HEALTH, EDUCATION, AND WELFARE T. S . PHS/CC

Documents

MANUAL: Personnel Chapter Series CC--Commissioned Corps