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INSPECTOR GENERAL

ACTION REQUEST FORM

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:                   Title 10, USC, Section 3020.

PRINCIPAL PURPOSE:     To secure sufficient information to inquire into the matters presented and to provide a response to the requestor(s) and / or take action to correct deficiencies.

ROUTINE USES:               Information in used for official purposes within the Department of Defense; to answer complaints or respond to requests for assistance, advice, or information: by Members of Congress and other Government agencies when determented by The Inspector General to be in the best interest of the Army; and, in certain cases, in trial by courts-martial and other military matters as authorized by the Uniform Code of Military Justice, Department of Defense Blanket Routine Uses also apply.

DISCLOSURE:                  PERSONAL INFORMATION IS VOLUNTARY, HOWEVER, FAILURE TO PROVIDE COMPLETE INFORMATION MAY HINDER PROPER IDENTIFICATION OF THE REQUESTOR, ACCOMPLISHMENT OF THE REQUESTED ACTION(S), AND RESPONSE TO THE REQUESTOR.

Last Name - First Name - Middle Initial: 

Grade/Rank:       Component/Status:   

Complete Military Address: 

Preferred Contact Telephone:    (Home)       (Duty)       (Cell)   

ADDRESS LINE 1: 

ADDRESS LINE 2: 

If country is not United States, you can type over the US in the country field to enter appropriate country.

CITY

STATE ZIP COUNTRY

Email Address: 

I do    I do not         consent to release my personal information outside official channels in order to resolve the matters listed about. I understand that if I do not agree to release my personal information, my request for assistance may go unresolved.

This information is submitted for the basic purpose of requesting assistance, correcting injustices affecting the individual, or eliminating conditions considered detrimental to the efficiency or reputation of the Army. Those who knowingly and intentionally provide false statements on this form are subject to punitive and administrative action (UCMJ Art 107, 18 USC 1001).

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