Form DD Form 1199 DD Form 1199 PENTAGON RESERVATION PARKING PERMIT APPLICATION

OMB No. 0704-0395
OMB approval expires:
XXXXXXX

PENTAGON RESERVATION PARKING PERMIT APPLICATION
(Read Agency Disclosure Notice and Privacy Act Statement on back before completing form.)
1. LAST NAME

2. FIRST NAME

3. MIDDLE NAME

4. SOCIAL SECURITY NUMBER

5. WORK E-MAIL ADDRESS

6. RANK (X one)
a. GENERAL SCHEDULE

b. SENIOR EXECUTIVE SERVICE

c. WAGE GRADE

d. OFFICER

e. ENLISTED

f. CONTRACTOR

g. AD (Administratively Determined)

h. OTHER (Specify)

7. GRADE/RANK

8. WORK LOCATION (X one)

9. ROOM NUMBER

a. PENTAGON

b. MARK CENTER

c. SUFFOLK

d. OTHER (Specify)
11. HOME ZIP CODE

10. WORK TELEPHONE NUMBER (Include area code)

13. AGENCY/DIVISION

12. DEPARTMENT (X one)
a. ARMY

b. AIR FORCE

c. NAVY

d. DEPARTMENT OF DEFENSE

e. OFFICE OF THE SECRETARY OF DEFENSE

NEEDS DD67

f. OTHER (Specify)
14. VEHICLE TAGS
a.(1) LICENSE PLATE
NUMBER

2) STATE

b.(1) LICENSE PLATE
NUMBER

(2) STATE

c.(1) LICENSE PLATE
NUMBER

(2) STATE

d.(1) LICENSE PLATE
NUMBER

(2) STATE

15. CAR POOLS AND VAN POOLS (X one)
a. CAR POOL (2 or more members)

b. VAN POOL (7 or more members)

16. ARE YOU APPLYING FOR A SINGLE OCCUPANCY VEHICLE (SOV) PERMIT?
a. YES

b. NO

17. DO YOU RECEIVE METRO SUBSIDY?
a. YES

b. NO

CERTIFICATION PERTAINING TO CAR/VAN POOL

I certify that I actively participate as a member of a reserved car/van pool. I understand that active participation means that I ride
to and from work as a member of the car/van pool except when on leave or other situations that would preclude travel on any given
day, for a distance of at least five miles. Further, I understand that administrative action will be taken to revoke my parking privilege
for falsifying my participation.
18.a. CAR/VAN POOL PRIMARY SIGNATURE

b. DATE (YYYYMMDD) 19.a. SOV APPLICANT/MEMBER SIGNATURE

20.a. CPR/AUTHORIZING OFFICIAL SIGNATURE

b. DATE (YYYYMMDD)

b. DATE (YYYYMMDD)

FOR OFFICE USE ONLY
21. PERMIT TYPE

24. PROCESSOR NAME (Last, First, Middle Initial)

22. PERMIT NUMBER

25. PROCESSOR SIGNATURE

23. PERMIT EXPIRATION DATE (YYYYMMDD)

26. SIGNATURE DATE
(YYYYMMDD)

DD FORM 1199, DRAFT 20190107

PREVIOUS EDITION IS OBSOLETE.

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mcalex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently
valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE PARKING
PERMIT OFFICE TO WHICH YOU ARE APPLYING.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2674, Operation and control of Pentagon Reservation and defense facilities in National Capital Region;
Administrative Instruction 88, Pentagon Reservation Vehicle Parking Program; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To manage the Pentagon Facilities Parking Program for DoD civilian, military, and contractor
personnel applying for and in receipt of Pentagon parking permits. Records are also used to ensure DoD military personnel and
civilians are not in receipt of both an issued parking pass and mass transit benefits.
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended.
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries, Disclosure to the Department of
Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use,
and Data Breach Remediation Purposes Routine Use.

NEEDS DD67

The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems
of records notices may apply to this system. The complete list of DoD Blanket Routine Uses can be found online at
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.
The applicable Privacy Act System of Records Notice is DWHS D04, Pentagon Facilities Parking Program found at
http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570582/dpfpa-02.aspx.
DISCLOSURE: Voluntary, however, failure to provide the requested information may require additional time to process the
application or result in denial for a parking permit.

DD FORM 1199 (BACK), DRAFT 20190107