JROTC INSTRUCTOR ANNUAL CERTIFICATION OF PAY AND DATA FORM
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2031, as amended, Junior Reserve Officers' Training Corps, Reserve Officers' Training Corps Program for Secondary
Educational Institutions; DoDI 1205.13, Junior Reserve Officer Training Corps (JROTC) Program; and DoDFMR 7000.14-R, Vol. 10, Chapter 21,
JUNIOR RESERVE OFFICER TRAINING CORPS (JROTC) INSTRUCTOR PAY.
PRINCIPAL PURPOSE(S): To determine the inclusive work dates of each instructor for employment period of JROTC Instructor duties.
ROUTINE USE(S): To the school/school district to provide information regarding the instructor's computed minimum instructor pay, and the amount
being reimbursed by the applicable Military Service. To the Treasury Department to provide information on check issues and electronic funds
transfers. The remaining routine uses are available in the applicable system of records notice T1205, Junior Reserve Officer Training Corps Payment
Reimbursement System, available at:
DISCLOSURE: Voluntary; however, failure to provide the requested information may impede or delay the reimbursement to the school.
2. DoD ID NUMBER
1. INSTRUCTOR NAME
(Last, First, Middle Initial)
6. RETIRED GRADE
5. BRANCH OF SERVICE
7a. NAME AND ADDRESS OF SCHOOL
8a. NAME AND ADDRESS OF SCHOOL DISTRICT
(Include ZIP Code)
(Include ZIP Code)
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
11. SCHOOL OFFICIAL
a. TYPED NAME (Last, First, Middle Initial)
c. TELEPHONE (Include Area Code)
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, DEC 2017
PREVIOUS EDITION IS OBSOLETE
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