ENCLOSURE (2) COMDTINST 1754.9A
REVERSE OF CG-5553 (10-92)
INFORMATION REQUIRED BY THE PRIVACY ACT OF 1974
Authority:
5 U.S.C. 5701-5742, 37 U.S.C. 404-427,
E.O. 9397, and 14 U.S.C 514.
Principal Purpose:
Used for reviewing, approving,
accounting, and disbursing for adoption
reimbursement, SSN is used to maintain a
numerical identification system for
individual claims (14 USC 514).
Routine Uses:
To substantiate claims for adoption
reimbursements.
Disclosure:
Voluntary. Failure to furnish
information requested may result in
total or partial denial of amount
claimed.
Member's Name (Print or Type) _______________________________________
Signature of Member __________________________________ Date _________
Address _____________________________________________________________
Work Telephone ______________________ Home Telephone ________________
SSN ________________________________ Unit ___________________________
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