JOINT INSPECTOR GENERAL ACTION REQUEST
Personal and Fraud, Waste and Abuse Complaint Registration
PRIVACY ACT STATEMENT
AUTHORITY: Title 10 U.S.C. 141; DoDD 5106.04; DoDI 5106.05.
PRINCIPAL PURPOSE(S): To secure sufficient information to inquire into the matters presented and to provide a response to the requestor(s) and/or
take action to correct deficiencies.
ROUTINE USE(S): Information is used for official purposes within the Department of Defense; to answer complainants or respond to requests for
assistance, advice, or information; by members of Congress and other Government agencies when determined by The Inspector General to be in the
best interest of the Department of Defense; and, in certain cases, in trial by courts-martial and other military matters as authorized by the Uniform
Code of Military Justice. Department of Defense "Blanket Routine Uses" also apply.
DISCLOSURE: Disclosure of personal information is voluntary; however, failure to provide complete information may hinder proper identification of
the requestor, accomplishment of the requested action(s), and response to the requestor.
WARNING: Those who knowingly and intentionally provide false statements in this complaint are subject to potential punitive and administrative
actions (UCMJ Art. 107; 18 U.S.C. 1001).
1. NAME (Last, First, Middle Initial)
3. SSN (Optional)
4. STATUS (X as applicable)
5. UNIT IDENTIFICATION CODE (UIC)/ORGANIZATION ADDRESS
6. PREFERRED MAILING ADDRESS (If different from above)
Foreign or Local
8. E-MAIL ADDRESS(ES)
7. CONTACT TELEPHONE NUMBER(S) (Include area code/DSN)
9. SPECIFIC ACTION REQUESTED (What do you want the IG to do for you?)
10. INFORMATION PERTAINING TO THIS REQUEST (Background, list attached documents, who else (commander, agency) you have talked with
about this matter, etc.)
11. STATEMENT OF UNDERSTANDING
I do not consent to release my personal information inside official channels in order to resolve the matter(s) listed above.
I understand that if I do not agree to release my personal information, my request for assistance may go unresolved.
a. DATE (YYYYMMDD)
12. IG/CASE NUMBER (Assigned by Joint IG)
DD FORM 2949, SEP 2011
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