Da Form 1559, Dec 2007 - Inspector General Action Request Template
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1INSPECTOR GENERAL ACTION REQUEST
For use of this form, see AR 20-1; the proponent agency is the Office of The Inspector General.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, USC, Section 3020; Inspector General Act of 1978 (Pub.L. 95-452), as amended; E.O. 9397 (SSN).
AUTHORITY:
To secure sufficient information to inquire into the matters presented and to provide a response to the requestor(s) and /
PRINCIPAL PURPOSE:
or take action to correct deficiencies.
ROUTINE USES:
Information is 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 determined 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
OF THE SOCIAL SECURITY NUMBER AND OTHER 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
SSN
COMPONENT / STATUS
UNIT AND COMPLETE MILITARY ADDRESS
PREFERRED CONTACT TELEPHONE
(Duty, home, and / or cell)
PREFERRED MAILING ADDRESS
(If different from military address, including ZIP Code)
E-MAIL ADDRESS
(Optional)
SPECIFIC ACTION REQUESTED (What do you want the IG to do for you?)
INFORMATION PERTAINING TO THIS REQUEST
(Background. Use additional sheets if necessary; list enclosures if applicable.)
I do
I do not
consent to release my personal information outside of IG channels (but within DoD official channels) in order to resolve the
matters listed above. 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 potential punitive and administrative action (UCMJ Art 107, 18 USC 1001).
SIGNATURE
DATE (YYYYMMDD)
APD PE v1.00ES
PREVIOUS EDITIONS ARE OBSOLETE.
DA FORM 1559, JUL 2011
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