Af Form 4422, 2010, Sex Offender Disclosure
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1SEX OFFENDER DISCLOSURE AND ACKNOWLEDGEMENT
Attach to application for military, government-managed and privatized housing
I, (print name)
, have read and understand the policy. By
signing this document, I certify under a penalty of perjury that neither I nor any person living in my
household is a registered sex offender or required to register as a sex offender. I understand I am required
to notify the installation housing office immediately if circumstances change so that this certification is no
longer true. I understand the policies, procedures and consequences below apply to those persons who
will reside with me, all of whom are listed on the DD Form 1746,
Application for Assignment to
Housing.
POLICIES
Air Force Installations requires full disclosure from persons applying for military, government-managed or
privatized housing who are sex offenders or who intend to have dependents who are sex offenders reside
with them.
If you, or an authorized dependent who will reside with you, are found to be registered or are required to
register as a sex offender under the laws of any state, you could be denied residency in Air Force military,
government-managed and privatized housing.
If you, anyone living in your household or visitor is found to be a sex offender after you take occupancy,
you may be subject to eviction and/or barment from the Installation.
Installation Commanders are authorized to approve or disapprove applications from persons for residency
in military, government-managed and privatized housing when they or another prospective resident of the
home is a sex offender.
PROCEDURES
Applicants who cannot sign this form because they or a dependent who will reside in the home with them is
a sex offender will be required to submit written information and documentation, which may include but is
not limited to the following, in order to be considered for housing by the Installation Commander:
1.
Whether the sex offender is the military member, civilian or dependent
Nature and circumstances of the offense
2.
3.
Exact criminal statute or law under which the person was convicted
State or jurisdiction where the offense occurred and was adjudicated
4.
5.
Elapsed time since the offense was committed
Age of the offender at the time the offense was committed
6.
7.
Age of the victim at the time the offense was committed
8.
Evidence that tends to demonstrate offender’s rehabilitation, exemplary conduct, or other commitment
to obeying the law
Whether the conviction requiring registration has been reversed, vacated, or set aside, or if the
9.
registrant has been granted unconditional pardon of innocence for the offense requiring registration
Conditions of parole/probation or monitoring, if any
10.
CONSEQUENCES
Falsification of this form or any other information pertaining to your criminal history or sexual offenses
will result in immediate denial of your application for or retention of military, government-managed or
privatized housing.
Signature of Applicant
Date
AF Form 4422 20100729
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