Appendix A 202D MILITARY INTELLIGENCE BATTALION
FAMILY SUPPORT INFORMATION FORM
Soldier's Name and Rank: ____________________________________________________
Section or Platoon: __________________________________________________________
Single: _____________ Married: ________________
Spouse's Name: ____________________
Mailing Address:
____________________________________________________________ Live in Barracks: ___________ or Residential Address: ______________________________ Home Phone:
_______________________ Spouse's Work Phone: ____________________ Name of Local Friend or Neighbor: ________________________ Phone: ______________
Other than Wife/Husband, who would you notify in case of emergency?
Name: ___________________________________________________________________
Address: Street & PO Box: __________________________________________________
City: ____________________ State: _______ Zip: __________
Country: ____________ Phone: ______________________ Relationship to you: ____________________________
SPECIAL FAMILY SITUATIONS: Mark (X) in appropriate spaces
______ Spouse has no driver's license
______ Medical Problems
______ No car
______ Exceptional Family Member
______ Spouse doesn't speak English. Spouse speaks: ______________________________
______ Wife is pregnant, Due Date: _____________________________________________
______ Other, Please explain: _________________________________________________
CHILDREN:
Name: __________________ Age: _________ Name:
__________________ Age: ____ Name: __________________ Age: _________ Name: __________________ Age: ____
PRIVACY ACT
STATEMENT: Authority U-S.C. 522a. and para 3-5, AR 340-2 1; para 2-8a. AR 210-7. Principal purpose is to gather data on family members of assigned soldier. Primary use of this
information is to facilitate volunteers in providing command information to family members concerning unit events and in emergencies. I understand that my phone number will be published on
the company spouses' roster that is available to company wives and the battalion chain of concern.
