Jrotc Instructor Annual Certification Of Pay And Data Form

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JROTC INSTRUCTOR ANNUAL CERTIFICATION OF PAY AND DATA FORM
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Section 2031; DoDI 1205.13, Junior Reserve Officer Training Corps (JROTC) Program; DoDFMR 7000.14-R, Vol. 10,
Chapter 21; and E.O. 9397.
PRINCIPAL PURPOSE(S): To determine the inclusive work dates of each instructor for employment period of JROTC Instructor duties.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information
contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD "Blanket
Routine Uses" published at the beginning of the DoD compilation of systems of records notices apply.
DISCLOSURE: Disclosure of this information is voluntary, however, failure to provide the requested information may impede or delay the
reimbursement to the school.
1. INSTRUCTOR NAME
2. SSN
(Last, First, Middle Initial)
3. SEX
4. STATUS
(X one)
(X one)
RETIRE/
FEMALE
NEW
RESIGN
MALE
RETURN
6. RETIRED GRADE
5. BRANCH OF SERVICE
(Retired from)
ARMY
AIR FORCE
NAVY
MARINE CORPS
COAST GUARD
7a. NAME AND ADDRESS OF SCHOOL
8a. NAME AND ADDRESS OF SCHOOL DISTRICT
(Include ZIP Code)
(Include ZIP Code)
NEW ADDRESS?
YES
NO
NEW ADDRESS?
YES
NO
b. SCHOOL/UNIT IDENTIFICATION NUMBER
b. DISTRICT IDENTIFICATION OR AREA NUMBER
9. CURRENT SCHOOL YEAR DATES OF WORK FOR JROTC
10. UPCOMING EMPLOYMENT PERIOD DATES OF WORK
(Not required for new hires)
(You MUST complete a separate sheet for any break in contract dates.)
a. FROM (YYYYMMDD)
b. TO (YYYYMMDD)
a. BEGINNING (YYYYMMDD)
b. ENDING (YYYYMMDD)
NOTE: Show the inclusive dates during which the individual will be performing DUTIES IN DIRECT SUPPORT OF JROTC, and for which the
minimum required salary will be due. Include only the period of time during which the instructor will ACTUALLY be working in support of JROTC.
These dates are subject to physical verification at any time by a representative from the applicable Military Service JROTC Headquarters. The
Military Service is authorized to reimburse the school for one-half the Minimum Instructor Pay unless other arrangements have been approved.
Reimbursement to the school/school district is only authorized for the period of time the instructor is covered by a valid contract, and is receiving
a salary equal to or greater than Minimum Instructor Pay as computed by the Military Service. This form is to be submitted to the appropriate
Military Service JROTC Instructor Reimbursement Office (JIRO) within 30 days of the instructor's employment, termination, and on a yearly basis
when requested by the JIRO (normally at the end of the school year). The school must immediately notify the appropriate JIRO of any changes
to dates indicated above.
11. SCHOOL OFFICIAL
a. TYPED NAME (Last, First, Middle Initial)
b. TITLE
c. TELEPHONE (Include Area Code)
d. SIGNATURE
e. DATE (YYYYMMDD)
12. INSTRUCTOR CERTIFICATION
I certify that I have been hired to instruct at the above school for the inclusive work period indicated and that the salary will be for
JROTC duties.
a. INSTRUCTOR SIGNATURE
b. DATE (YYYYMMDD)
DD FORM 2767, SEP 2007
PREVIOUS EDITION IS OBSOLETE
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