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    DD1561

    Uploaded by

    Jeff Peterson
    This document contains a Privacy Act Statement and form for substantiating payment of Family Separation Allowance (FSA). The form collects personal information from the service member and certifying officer to determine eligibility for FSA payments when service members are separated from their dependents due to military orders or duty assignments. Information provided includes names, social security numbers, dependent addresses, dates and locations of temporary duty assignments, and certifications of dependency status and housing arrangements.

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    Attribution Non-Commercial (BY-NC)
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    DD1561

    Uploaded by

    Jeff Peterson
    174 views1 page
    This document contains a Privacy Act Statement and form for substantiating payment of Family Separation Allowance (FSA). The form collects personal information from the service member and certifying officer to determine eligibility for FSA payments when service members are separated from their dependents due to military orders or duty assignments. Information provided includes names, social security numbers, dependent addresses, dates and locations of temporary duty assignments, and certifications of dependency status and housing arrangements.

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    This document contains a Privacy Act Statement and form for substantiating payment of Family Separation Allowance (FSA). The form collects personal information from the service member and certifying officer to determine eligibility for FSA payments when service members are separated from their dependents due to military orders or duty assignments. Information provided includes names, social security numbers, dependent addresses, dates and locations of temporary duty assignments, and certifications of dependency status and housing arrangements.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    174 views1 page

    DD1561

    Uploaded by

    Jeff Peterson
    This document contains a Privacy Act Statement and form for substantiating payment of Family Separation Allowance (FSA). The form collects personal information from the service member and certifying officer to determine eligibility for FSA payments when service members are separated from their dependents due to military orders or duty assignments. Information provided includes names, social security numbers, dependent addresses, dates and locations of temporary duty assignments, and certifications of dependency status and housing arrangements.

    Copyright:

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    STATEMENT TO SUBSTANTIATE PAYMENT OF FAMILY SEPARATION ALLOWANCE (FSA)

    PRIVACY ACT STATEMENT


    AUTHORITY: Title 37, U.S. Code, Section 427.
    PRINCIPAL PURPOSE: To evaluate member's application for FSA.
    ROUTINE USES: a. Serves as substantiating document for FSA payments and input into the member's pay account.
    b. Provides an audit trail for validating propriety of payments and to assist in collecting erroneous payments.
    c. Provides a record in service member's pay account and for safekeeping.
    DISCLOSURE: Disclosure of your social security number and other personal information is voluntary. However, if requested information
    is not provided, FSA will not be considered.
    1. NAME OF MEMBER (Last, First, Middle Initial) 2. GRADE 3. SOCIAL SECURITY NUMBER 4. BRANCH AND ORGANIZATION

    PART I - MEMBER COMPLETES THIS SECTION TO SUBSTANTIATE ENTITLEMENT TO FSA


    5. TYPE II (X as applicable) 6. COMPLETE CURRENT ADDRESS(ES) OF DEPENDENT(S)
    FSA-T (Temporary) FSA-R (Restricted) FSA-S (Ship)
    7. DATE (DDMMYY) DEPARTED RESIDENCE TO UNIT HOME
    STATION (Mobilized Members)

    8. I CERTIFY TO THE FOLLOWING FACTS (X applicable box(es))


    a. I am not divorced or legally separated from my spouse.
    b. My dependent child (children) was (were) not in the legal custody of another person when I received my military orders.
    c. My dependent (other than my spouse; see line f. below) is not a member of the military service on active duty.
    d. My sole dependent is not in an institution for a known period of over 1 year or a period expected to exceed 1 year.
    e. I am claiming FSA for my parent(s) for whom I have a current and approved dependency status and am residing with, and I maintain a
    residence(s) for my dependent(s). I have assumed the liability and responsibilities thereof at the address(es) shown above, where I likely
    reside during periods of leave or such other times as my duty assignment may permit.
    f. I am married to another military member currently serving on active duty and my spouse was was not residing with me immediately
    before being separated by execution of my military orders.
    Spouse's SSN: Branch and Component:
    g. My last TDY or deployment, if any, was was not within the last 30 days from this TDY or deployment.

    9. I understand that I must notify my commanding officer immediately upon any change in dependency status and if my sole dependent or all of my
    dependents move to or near this station or if my dependent(s) visit at or near this station for more than 90 continuous days (more than 30
    continuous days in the case of FSA-T (Temp) or FSA-S (Ship) while I am in receipt of FSA.
    a. DATE (DDMMYY) b. SIGNATURE OF MEMBER

    PART II - CERTIFYING OFFICER COMPLETES THE APPROPRIATE SECTION(S) BELOW


    10. TYPE II - FSA-T. Member has been ordered to and has performed temporary duty (TDY) at the location(s) shown below for more than 30
    continuous days. This (these) location(s) is (are) outside a reasonable commuting distance from the member's permanent duty station (PDS
    pertains to active component) or the home of residence (HOR pertains to reserve component). A distance of 50 miles, one way, is normally
    considered to be within a reasonable commuting distance of a PDS or HOR. "Within a reasonable commuting distance" also may include
    distances of less than 50 miles and the time required to travel, under unusual conditions, does not exceed 1-1/2 hours. (Attach a blank page for
    continuation if necessary.)
    a. LOCATION b. INCLUSIVE DATES OF TDY/T (From/To) c. NO. OF DAYS

    11. TYPE II - FSA-R. Member departed (PCS/detached) from on


    (Last permanent duty station) (DDMMYY)
    and was on leave en route , proceed time
    (Inclusive leave dates - DDMMYY) (Inclusive dates)
    and the member reported to on . Transportation of
    (PDS) (DDMMYY)
    dependent(s) is not authorized at government expense to this station or to a place near this station.

    12. TYPE II - FSA-S. Member was serving on orders, on board ship, away from homeport commencing (DDMMYY) .
    a. NAME OF SHIP/UNIT b. HOMEPORT

    13. Travel performed under authority of orders , dated .

    14. Member claiming Type II FSA, is receiving basic allowance for housing (BAH) (or residing in government type quarters) as a member with
    dependents or member married to a military member.
    15. DATE (DDMMYY) 16. CERTIFYING OFFICER
    a. TYPED NAME (Last, First, Middle Initial) b. TITLE

    c. ORGANIZATION d. SIGNATURE

    DD FORM 1561, NOV 2006 PREVIOUS EDITION IS OBSOLETE Adobe Professional 7.0
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