ENCLOSURE (3) TO COMDTINST 1754.9A
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
forindividual claims.
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.
I certify that the above information and expenses are true and correct to the best of my
knowledge. I understand and agree that reimbursement of expenses is limited to ,000 per
adopted child with maximum reimbursement of ,000 in any calendar year. I agree not to seek
further reimbursement under this program for the adoption of this child. To the best of my
knowledge, I am the only active duty member of the Armed Forces claiming for this child
reimbursement of $ _____________.
Signature of Member _________________________ Date __________.
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