Dd Form 1607, 2010, Application For Homeowners Assistance Page 4
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525. (BRAC APPLICANTS ONLY) POINT OF CONTACT TO ALLOW GOVERNMENT CONTRACTORS TO GAIN ACCESS TO YOUR DWELLING
(For Army Corps of Engineers' appraiser and inspector for environmental hazards)
b. HOME TELEPHONE (Include area code)
c. WORK TELEPHONE (Include area code)
a. NAME (Last, First, Middle Initial)
d. ADDRESS
(1) STREET (Include apartment number)
(2) CITY
(3) STATE
(4) ZIP CODE
26. POINT OF CONTACT THAT KNOWS YOUR WHEREABOUTS AT ALL TIMES
(Someone who does not live with you)
b. HOME TELEPHONE (Include area code)
a. NAME (Last, First, Middle Initial)
SECTION III - DECLARATION
CRIMINAL PENALTY FOR PRESENTING FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS
Fine of not more than $10,000 or imprisonment for not more than 5 years or both (See 62 Stat. 698, 749; 18 USC 287, 1001).
CIVIL PENALTY FOR PRESENTING FRAUDULENT CLAIM
The applicant shall forfeit and pay to the United States the sum of not less than $5,000 and not more than $10,000 plus 3 times the
amount of damages sustained by the United States (See 31 USC 3729).
27. I DECLARE UNDER THE PENALTIES OF PERJURY THAT THE INFORMATION PROVIDED BY ME HEREIN AND ATTACHED IS TRUE AND
COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
a. I APPLY FOR HOMEOWNERS ASSISTANCE IN THE FOLLOWING CATEGORY: (X as applicable)
(1) FORECLOSURE RELIEF (For applicants whose homes have been foreclosed)
(2) REIMBURSEMENT FOR LOSS ON PRIVATE SALE (For applicants whose homes have been sold or who plan to sell)
(3) GOVERNMENT ACQUISITION (For applicants who still own their homes) (Not available in foreign countries)
I voluntarily request and give my consent to the disclosure of my personal information. I am aware that I may revoke my consent at any
time by doing so in writing. This Consent is valid for one year from the date of authorization.
b. SIGNATURE (To be used in all future correspondence)
c. DATE SIGNED (YYYYMMDD)
SECTION IV - VERIFICATION OF EMPLOYMENT OR SERVICE (To be completed by Personnel Office)
28. REVIEW OF APPLICANT'S OFFICIAL PERSONNEL FOLDER INDICATES:
(X and complete as applicable)
a. THE EMPLOYMENT/SERVICE INFORMATION SHOWN ON THIS FORM HAS BEEN VERIFIED AND IS CORRECT AS STATED IN ITEMS 1, 8, AND 10.
b. THE EMPLOYMENT/SERVICE INFORMATION SHOWN ON THIS FORM IS NOT CORRECT. THE PERSONNEL FOLDER SHOWS THE FOLLOWING:
29. PERSONNEL OFFICER
b. TITLE
a. NAME (Last, First, Middle Initial)
c
. UNIT ADDRESS
(1) STREET
(2) CITY
(3) STATE
(4) ZIP CODE
d. SIGNATURE
e. DATE SIGNED (YYYYMMDD)
DD FORM 1607, DEC 2010
Page 3 of 4 Pages
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