Aer Form 600 - Commander'S Referral Program Application For Army Emergency Relief (Aer) Financial Assistance Page 5

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A
C
S
C
I
S
RMY
OMMUNITY
ERVICE
LIENT
NFORMATION
HEET
PRIVACY ACT STATEMENT
PRINCIPAL:
To collect data necessary to enroll DOD personnel and their family members in the Army
Community Service client database. Also used as a tool to aid in delivery of services to
DOD personnel and their family members. Statistical data will be provided to Department
of the Army.
ROUTINE USES:
Used as a record of (1) services requested; (2) services delivered; and (3) actions or
services agreed upon. Upon data entry, form will be filed.
DISCLOSURE:
Disclosure of information is voluntary. Failure to provide required information may result
in the inability of Army Community Service to provide appropriate professional and/or
development services to the individual.
DATE:
YOUR SSN:
LAST NAME:
FIRST NAME:
MI:
 Male
 Female
GENDER:
BIRTH DATE: ____________________
TYPE OF VISIT:  Individual
 Couple
 Family
REASON FOR VISITING ACS:
REFERRED TO ACS BY:
(select the most appropriate)
 Self-referral
 Command
 Volunteer
 JAG (Legal)
 Military Medical
 Other
 Civilian Agency
 Chaplain
YOUR ELIGIBILITY STATUS:
(select one)
 Active Duty
 Retired
 Family Member
 Gov’t Civilian
 Reserve/National Guard
SPONSOR’S BRANCH OF SERVICE:
 Army
 Air Force
 Coast Guard
 Navy
 Marines
MARITAL STATUS:
(select the most appropriate)
 Married ______ # of times
 Divorced
 Widow(er)
 Single
 Separated
 Dual Military
 Single Parent
Continued on reverse…
REVISED ON: 22-Mar-12

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