DA Form 5960 - Fill, Sign Online, Download & Print - No Signup
DA FORM 5960, JAN 2022
APD AEM v1.00ES
PREVIOUS EDITIONS ARE OBSOLETE.
1. Name
(Last, First, MI)
2. DOD ID Number
3. Grade
4. Member's Physical Addr
ess (Street, City, State, and Zip Code)
AUTHORITY:
37 USC 403, Basic allowance housing; Army Regulation 637-1, Army Military Compensation and Entitlement Policy.
PRINCIPAL PURPOSE:
To start, adjust or terminate a Soldier's entitlement to basic allowance for housing (BAH) and to verify a Soldier's
dependency status. For additional information see the System of Records Notice A0600-8-104 APS
http://www.federalregister.gov/documents/2019/07/18/2019-15242/privacy-act-of-1974-system-of-records
.
ROUTINE USES:
DISCLOSURE:
PRIVACY ACT STATEMENT
BASIC ALLOWANCE FOR HOUSING (BAH)
AUTHORIZATION AND DEPENDENCY DECLARATION
For use of this form, see AR 637-1. The proponent agency is DCS, G-1.
17. Date
5. Duty Location
(Unit Location or City, State, and Zip Code)
12. Other Dependent Information
(Children and Secondary Dependents)
. Additional Dependents Will Be Listed On Additional Forms
Voluntary; however, form will not be processed without your DoD ID for pay purposes and nondisclosure may result in
discrepancies with your BAH.
6. Effective Date Of Action
7. Type Of Action
(Select Only One)
8. BAH Type
(Select Only One)
9. Marital Status
(Select Only One)
10. Spouse's Name
(Last, First, MI)
11. Spouse's Physical Address
(Street, City, State, and Zip Code)
Has your spouse or former spouse ever served in a
branch of the Uniformed Services?
(If Yes, complete
blocks a, b, c & d)
a. Spouse's DOD ID Number
b. Spouse's Branch Of Service
c. Date Spouse Last Entered Service
d. Date Spouse Last Separated Service
YES
NO
15. Date
Start
Change
Stop
Recertify
Divorced
Single
Married
Legally
Separated
Differential
With
Dependents
Without
Dependents
Widowed
Relationship
Date Of Birth
Physical Address
Name
Custody
Physical
Legal
Read and Initial: I understand that a legal separation agreement, court decree, judgment, or order that does not state the dependent support
amount, or absolves me of my dependent support responsibility, does not of itself affect my housing allowance. I further understand that if I am
authorized a housing allowance on behalf of a dependent that I must contribute to my dependent's support in an amount that is not less than
the applicable BAH-DIFF rate.
Read and Initial: I understand that the legal purpose of a housing allowance on behalf of a dependent is to partially reimburse a Service
Member for the expense of providing a private sector residence for the dependents when Government Quarters are not provided. I further
understand that a housing allowance for a dependent is not a bonus merely for the technical status of being married or a parent.
Read and Initial: I understand that I am required to provide adequate support to those dependents on whose behalf I am receiving a housing
allowance and if I fail to provide adequate support, the housing allowance that I received for that dependent will be recouped for nonsupport or
inadequate support periods.
Read and Initial: I understand that if there is a court order or legal separation agreement stating the support amount, I must contribute to the
dependent's support the amount specified therein, but in no case may the support payments be less than the applicable BAH-DIFF rate.
Read and Initial: I certify that I provide or am willing to provide adequate support to the above named dependents.
13. Certification of Dependent Support
I certify ALL information regarding this authorization is correct. I will immediately notify the servicing Finance/Personnel Office of any
changes in the information above, due to divorce, marriage, death, living in government quarters etc., which could affect my BAH entitlement.
To the Internal Revenue Service for tax purposes. To the U.S. Government Accountability Office for statistical management
To the members of Congress for inquiries. To U.S. state courts and various law enforcement agencies by subpoena only.
14. Member's Signature
16. Commander's Signature
IMPORTANT:
Making a false statement or claim against the US Government is punishable by courts-martial. The penalty for willfully making a false
claim or a false statement in connection with claims is a maximum fine of $10,000 or imprisonment for 5 years, or both.
