Employment Application



REQUEST FOR CASUALTY ASSISTANCE / MILITARY FUNERAL HONORS OF ARMY PERSONNELPRIVACY ACT STATEMENTCasualty Assistance Office4700 Mow Way Road, Suite 143, Room 143N Fort Sill, OK 73503(580) 442-6405/8592 or Fax (580) 442-6914Office Hours: Monday-Friday 0730-1630 Nights, Weekends and Holidays please call: (580) 512-6178: AR 600-25;Title 5, USC 3331, 552, 552a; 10 USC 10204; EO 10450, 10865, and 12333.Principal Purpose: The information requested is for the purpose of providing funeral honors fordeceased Army personnel.Routine Use: Normal Office Use. The Social Security Number (SSN) and other personally identifiableinformation are required for record accuracy, they are requested pursuant to EO 9397.Disclosure: Providing requested information, to include your SSN, is voluntary. However, failure toprovide information may delay services to be provided until authenticity can be verified by an alternatemethod. This document contains personal or privileged information and should be treated as "ForOfficial Use Only (FOUO)".1. Next of Kin Requests (check all that apply)Funeral Honor TeamYesNo If yes, (select only one below)At ServiceorAt GravesideChaplain SupportYesNo If yes, (select only one below)At ServiceorAt Graveside2. Deceased InformationName (Last, First, MI)Social Security Number--RankDate Retired (mm/dd/yyyy)Religious PreferenceRaceDate of MarriagePlace of MarriageStatus (Army only) (Check One)RetireeVeteranActive DutyDependentComponent (Check One)Regular ArmyNational GuardReserveCause of DeathDate of DeathTime of Deatha.m.p.m.Place of Death (Medical Facility if any, City and State)Date of BirthPlace of Birth (City and State)3. Next of Kin (NOK or Sponsor's) InformationName (Last, First, MI)Social Security Number--Date of BirthRelationship to DeceasedNOK Address (Street, City, State and Zip Code)NOK Phone #--Is this the person to receive the FlagYesNoIf no, please list name:4. FuneralFuneral HomeFuneral Home Address (Street, City, State and Zip Code)Funeral Home DirectorFuneral Home Phone NumberType of Service:CasketUrnOther (e.g., Memorial Service)Do you have a FlagYesNoName of church or chapel where Services will be heldAddress (Street, City, State and Zip Code)Church or Chapel Phone NumberFuneral DateFuneral Timea.m.p.m.5. BurialBurial must be scheduled 72 hours in advance to ensure military honors. Funeral Directors must schedule on-post burial with Cemetery Operations at (580) 442-6720Cemetery NameAddress (Street, City, State and Zip Code)Cemetery Phone NumberBurial DateBurial Timea.m.p.m.Is this a Graveside Only serviceYesNo6. Office Use OnlyMilitary Police Escort CoordinatedYesNoApproximate Time arriving(If "Yes", list gate entering Fort Sill):a.m.p.m.Chaplain Coordination madeYesNoBand Coordination made:YesNoLive Bugler:YesNoBag Piper:YesNoUnits TaskedDate and Time Request Received in Office:a.m.p.m.USARARNG30th ADADate and Time Funeral Home POC Contacted:a.m.p.m.434th FA31st ADA75th BDEName of POC Contacted:428th FAOKNGFCOEOther (Please identify below)Name of CAC Staff Making Contact and Coordination:FS FORM 733, APRIL 2019(DIRECTORATE OF HUMAN RESOURCES) ................
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