Ver 2.8

1. TYPE SERVICE DESIRED (X one or both)

APPLICATION FOR ASSIGNMENT TO HOUSING(Before completing form, read Privacy Act Statement and Instructions on reverse)

SECTION I - APPLICANT INFORMATION
2. NAME OF SPONSOR (Last, First, Middle Initial)

3. PAY GRADE

6. ADDRESS (Street, City, State, Zip Code)

7. TELEPHONE NUMBER
a.

a. MI LI TARY HOUSI NG

4. SSNHOME (Area Code)9. MARITAL STATUS

5. DOD COMPONENT
8. STATUS OF APPLICANT (X one)b. DUTY (DSN)

a. MI LI TARY MEMBER

c. CI VI LI ANb. MI LI TARY SPOUSE

d. FOREI GN NATI ONAL

10. I AM SEPARATED FROM MY DEPENDENTS (X one)a. VOLUNTARI LY

11. I REQUEST HOUSING FOR (X one)a. SELF ONLY

b. HOUSI NG REFERRAL

b. I NVOLUNTARI LY

SECTION II - MILITARY CAREER INFORMATION (Civilians skip to Item 15.)
14. DATES (Enter in YYMMDD order)
MI LI TARY APPLI CANT MI LI TARY SPOUSE

b. SELF AND DEPENDENTS

12. INSTALLATION/ORGANIZATION TRANSFERRED FROM

a. EFFECTI VE RANK/ RATE DATE
b. ACTI VE DUTY SERVI CE COMPUTATI ON
c. TI ME REMAI NI NG ON ACTI VE DUTY

13. INSTALLATION/ORGANIZATION TRANSFERRED TO

d. EFFECTI VE CHANGE I N DUTY STATI ON
e. REPORT DATE
f. ESTI MATED FAMI LY ARRI VAL DATESECTION III - DEPENDENT DATA
15. DEPENDENTS RESIDING WITH ME (If more space is needed, continue on plain paper.)b. DATE OF BI RTH

a. NAME (Last, First, Middle Initial)(YYMMDD)

c. SEX

d. RELATI ONSHI P

e. REMARKS (Handicap, health problems, expected additions

to family, etc.)

SECTION IV - HOUSING DATA
16. COMMUNITY HOUSING DESIRED (X as applicable)
a. PURCHASE HOUSE

d. RENT HOUSE

g. RENT MOBI LE HOME SPACE

j.

b. PURCHASE CONDOMI NI UM

e. RENT APARTMENT

h. SHARE

k. SUBLET

c. PURCHASE MOBI LE HOME

f. RENT MOBI LE HOMEi.

RENT ROOM

18. DATE HOUSING NEEDED

17. AMENITIES DESIRED (X as applicable. Write number in d. and e.)l.

e. NO. BATHS

b. UNFURNI SHED

f. PETS (Allowed)

c. AI R CONDI TI ONI NG

g. OTHER (Explain)

TRANSI ENT

19. PRICE RANGE(YYMMDD)
a. FURNI SHEDROOM AND BOARD(Community Housing)

20. LOCATION PREFERENCE (Community Housing)d. NO. BEDROOMS

21. REMARKS
Duty Email:

I,Personal Email:Give the Housing Office authorization to release myCell Phone:

Privacy Act Information to The Property Owner

Spouse Phone:
Spouse Email:Number of Pets:
22. SIGNATURE OF APPLICANT

23. DATE SUBMITTED(YYMMDD)SECTION V - DISPOSITION (To be completed by the Housing Office.)
24. MILITARY HOUSINGa.

e.

APPLI CATI ON RECEI VED(YYMMDD and time)b. APPLI CATI ON EFFECTI VE (YYMMDD)

c. DD FORM 1747 PROVI DED

APPLI CANT PLACED ON WAI TI NG LI ST

f. EFFECTI VE PLACEMENT (YYMMDD)

g. BEDROOMS REQUI RED

d.

(YYMMDD)

HOUSI NG AVAI LABI LI TY (Boxesindicated on DD Form 1747)h.

DATE UNI T ASSI GNED (YYMMDD)SECTION VI - HOUSING REFERRAL CERTIFICATEOn this date I have received a listing of the housing restrictions approved
I n addition, if any facility refuses to rent or sell to me or I haveby the I nstallation Commander, and I will not reside in any property on the reason to believe I am being discriminated against, I will promptly notify
restricted list. I have been briefed on (1) the services provided by the the Housing Office.
Housing Office, (2) the DoD program on equal opportunity for military 25. SIGNATURE OF APPLICANT
26. DATE SIGNED(YYMMDD)
personnel in off-base housing, and (3) nondiscrimination based on physicalor mental handicaps.

DD Form 1746, SEP 93

Previous editions may be used.

Adobe Professional 8.0

SEX OFFENDER DISCLOSURE AND ACKNOWLEDGEMENT

Attach to application for military, government-managed and privatized housingI, (print name), have read and understand the policy. Bysigning this document, I certify under a penalty of perjury that neither I nor any person living in myhousehold is a registered sex offender or required to register as a sex offender. I understand I am required
to notify the installation housing office immediately if circumstances change so that this certification is nolonger true. I understand the policies, procedures and consequences below apply to those persons whowill reside with me, all of whom are listed on the DD Form 1746, Application for Assignment toHousing.

POLICIES

Air Force Installations requires full disclosure from persons applying for military, government-managed orprivatized housing who are sex offenders or who intend to have dependents who are sex offenders residewith them.
If you, or an authorized dependent who will reside with you, are found to be registered or are required toregister as a sex offender under the laws of any state, you could be denied residency in Air Force military,
government-managed and privatized housing.
If you, anyone living in your household or visitor is found to be a sex offender after you take occupancy,
you may be subject to eviction and/or barment from the Installation.
Installation Commanders are authorized to approve or disapprove applications from persons for residency
in military, government-managed and privatized housing when they or another prospective resident of thehome is a sex offender.
PROCEDURES
Applicants who cannot sign this form because they or a dependent who will reside in the home with them isa sex offender will be required to submit written information and documentation, which may include but is
not limited to the following, in order to be considered for housing by the Installation Commander:

1.
2.
3.
4.
5.
6.
7.
8.

Whether the sex offender is the military member, civilian or dependent
Nature and circumstances of the offense
Exact criminal statute or law under which the person was convicted
State or jurisdiction where the offense occurred and was adjudicatedElapsed time since the offense was committed
Age of the offender at the time the offense was committed

Age of the victim at the time the offense was committed
Evidence that tends to demonstrate offender’s rehabilitation, exemplary conduct, or other commitment
to obeying the law
9. Whether the conviction requiring registration has been reversed, vacated, or set aside, or if theregistrant has been granted unconditional pardon of innocence for the offense requiring registration
10. Conditions of parole/probation or monitoring, if anyCONSEQUENCES
Falsification of this form or any other information pertaining to your criminal history or sexual offenses
will result in immediate denial of your application for or retention of military, government-managed orprivatized housing.

Signature of Applicant

AF Form 4422 20100729

Date

APPLICATION FOR ASSIGNMENT TO HOUSINGPRIVACY ACT STATEMENTAUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USE:DISCLOSURE:

5 USC 5911 & 5912.
To identify customer needs for assistance and housing requirements.
None.
Voluntary; however, failure to provide the requested information will result in our inability to assist you.
GENERAL INSTRUCTIONSThis form provides the Housing Office with information that will be used to provide you with military and/or community housing. All items not listed are
self-explanatory. SECTION I (APPLICANT INFORMATION), SECTION II (MILITARY CAREER INFORMATION), SECTION III (DEPENDENT DATA), AND
SECTION VI (HOUSING DATA) are to be completed by the applicant. Information on military spouses is now being requested for Basic Allowance forQuarters (BAQ) entitlement which must be included on your Military Pay Order that is forwarded to your respective financial center.

1. TYPE SERVICE DESIREDSECTION III - DEPENDENT DATA

Military Applicants: If temporary community housing isdesired while awaiting military housing, mark both boxes inItem 1, and answer all questions.

15. DEPENDENTS RESIDING WITH ME

Civilian Applicants: Mark the box "Housin g Referral"
services in Item 1b, and answer all questions.
SECTION I - APPLICANT INFORMATIONe. Provide the Housing Office with information regarding any
handicapped dependent or special family health problems thatmight influence your preference for a particular type of housing;i.e., single level vs. two story, ramps for wheelchairs, expected
additions to family, etc.

5. DOD COMPONENTSECTION IV - HOUSING DATA

Arm y, Navy, Air Force, etc.
6. ADDRESSEnter com plete current address (street number and name,apartment number, city, state/country and the 9-digit ZIP code).
12. INSTALLATION/ORGANIZATION TRANSFERREDFROMEnter the name of the installation you transferred from.
13. INSTALLATION/ORGANIZATION TRANSFERRED TOEnter the name of the installation to which you are applyingfor housing. Include the name of the Organization/ Department
you will be assigned to.
SECTION II - MILITARY CAREER INFORMATION
14. DATES (Military Applications/Military Spouse Only)Enter dates in order of YYMMDD. (May 17, 1993, wouldbe entered as 930517).
a. Enter the date your current rate/ rank was effective.
b. Enter your active duty service computation date.
c. Enter the time (in months) that you have remaining on activeduty.
d. Enter the effective date you were dropped fromaccountability at your previous duty station and gained on therolls at your new duty station for record purposes. For overseas
assignment, enter your date of departure from CONUS.
e. Enter your official report date (from your PCS orders).
f. Enter your estimated arrival date.
DD Form 1746, SEP 93

a. through d. List requested data for all authorized dependents
who will be residing with you.

16 - 21. Self-explanatory.
22. SIGNATURE
The applicant must sign the DD Form 1746.
23. DATE SUBMITTEDEnter the date the application was submitted to the Housing
Office.
SECTION V - DISPOSITION (To be completed by theHousing Office)24. MILITARY HOUSING
a. Application Received. Enter the year, month, day andtime the application was received in the Housing Office.
b. Application Effective. Enter the date of change of duty
station (Line 14d) or other date that will be the effective (control)date.
c. DD Form 1747 Provided. Enter the date that the DD
Form 1747 was sent to the military applicant.
d. Housing Availability. Enter the item letter for theapplicable box(es) marked under Item 4 of the DD Form 1747
returned to the applicant.
e. Applicant Placed on Waiting List. Enter the identificationof the assignment waiting list(s) to which the applicant is placed.
f. Effective Placement. The effective date and time of theapplicant's placement on the list(s).
g. Bedrooms Requirement. Enter the num ber of bedrooms
required, based on dependent data in Item 15.
h. Date Unit Assigned. Enter the date the unit was assigned.