TATTOO/BRAND/BODY MARKING SCREENING/VERIFICATION
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 8013, Secretary of the Air Force, Executive Order 9397 (SSN), as amended.
PURPOSE: To provide personnel management support to commanders and supervisors.
ROUTINE USE: Disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act. DoD 'Blanket Routine Uses' apply.
DISCLOSURE: Voluntary, failure to provide SSN may impede proper placement in member's military personnel file.
WARNING:
The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a
$10,000 fine or both), to anyone making a false statement. If you knowingly and willingly provide a false statement you can be tried by military courts
-martial or meet an administrative board for discharge and could receive a less than honorable service characterization.
SECTION I. AIRMAN
b. DATE OF BIRTH (YYYYMMDD)
a. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)
c. SOCIAL SECURITY NUMBER
SECTION II. IDENTIFICATION
Commander marks all tattoo/brand/body markings with a number and Airman initials
Commander describes tattoo/brand/body marking information below and Airman initials
Front
Back
Number on
Location
Description, Size, Shape and Meaning
Initials
Body Diagram
PREVIOUS EDITIONS ARE OBSOLETE
PRIVACY ACT INFORMATION: The information in this form is
AF FORM 4428, 20110831
FOR OFFICIAL USE ONLY. Protect IAW the Privacy Act of 1974.