0704-0152_pia_9.12.2018

PRIVACY IMPACT ASSESSMENT (PIA)
PRESCRIBING AUTHORITY: DoD Instruction 5400.16, "DoD Privacy Impact Assessment (PIA) Guidance". Complete this form for Department of Defense
(DoD) information systems or electronic collections of information (referred to as an "electronic collection" for the purpose of this form) that collect, maintain, use,
and/or disseminate personally identifiable information (PII) about members of the public, Federal employees, contractors, or foreign nationals employed at U.S.
military facilities internationally. In the case where no PII is collected, the PIA will serve as a conclusive determination that privacy requirements do not apply to
system.
1. DOD INFORMATION SYSTEM/ELECTRONIC COLLECTION NAME:
) DD 2475 - DoD Educational Loan Repayment Program Annual Application
2. DOD COMPONENT NAME:

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�ssistant Secretary of Defense - Reserve Affairs

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3. PIA APPROVAL DATE:

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SE�IIQtj :I: ell !lESCBlern:u� SUMMABY (EQB euaLIC RELEASE)
a. The PH Is: (Check one. Note: foreign nationals are included in general public.)

D

From members of the general public

00

From Federal employees and/or Federal contractors

D

From both members of the general public and Federal employees and/or
Federal contractors

D

Not Collected (if checked proceed to Section 4)

D

New Electronic Collection

b. The Pll ls in a: (Check one)

D
D
D

New DoD Information System

00

Existing DoD Information System

Existing Electronic Collection

Significantly Modified DoD Information System

c. Describe the purpose of this DoD information system or electronic collection and describe the types of personal information about individuals
collected In the system.
l·or the Mt11tary service to pay a portion of"a Service Member's student loan(s). The mtormatton provided will be reviewed by Mllltary
Service personnel record custodians to verify that eligibility requirements are met. The form will be forwarded to the lender that is identified
for verification of the loan amount and status. The form is returned to the Service finance office to make the annual oavment to the lender.

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d. Why Is the PII collected and/or what is the intended use of the PII? (e.g., verification, identification, authentication, data matching, mission-related use,
administrative use)

Verification that Service Member eligibility requirements are met
e. Do Individuals have the opportunity to object to the collection of their PII?

00

Yes

D

No

00

Yes

D

No

(1) If "Yes," describe the method by which individuals can object to the collection of PII.

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(2) If "No," state the reason why individuals cannot object to the collection of PII.
U1sclosure ot the requested mtormat1on 1s voluntary
f. Do individuals have the opportunity to consent to the specific uses of their PII?
(1) If ''Yes," describe the method by which individuals can give or withhold their consent.
(2) If "No,'' state the reason why individuals cannot give or withhold their consent.
By s1gnmg the form, the Service Member authorizes the release of the financial data by lender/holder to complete entries.

g. When an individual is asked to provide PII, a Privacy Act Statement (PAS) and/or a Privacy Advisory must be provided. (Check as appropriate and
provide the actual wording.)

00

Privacy Ad Statement

D

Privacy Advisory

D

Not Applicable

PRIVACY ACI �TAThMhN 1
AUTHORITY: 10 U.S.C. 2171, Education Loan Repayment Program: Enlisted Members on Active Duty in Specified Military Specialties;
2173, Education Loan Repayment Program: Commissioned Officers in Specified Health Professions; 16301, Education Loan Repayment
Program: Members of Selected Reserve; 16302, Education Loan Repayment Program: Health Professions Officers Serving in Selected
Reserve with Wartime Critical Medical Skill Shortages; 16303, Loan Repayment Program: Chaplains Serving in the Selected Reserve, and
E.O. 9397, Social Security Number (SSN).

DD FORM 2930, JUN 2017

PREVIOUS EDITION IS OBSOLETE.

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NCI.t'AL PUKPUSE(':s): ln completmg this torm, you are requestmg your M1I1tary service to pay a portion ot"your student Ioan(s). ·1ne
information you provide will be reviewed by Military Service personnel record custodians to verify that you meet eligibility requirements.
This form will then be forwarded to the lender that you identify for verification of the loan amount and status. The form is returned to the
Service finance office to make the annual payment to your lender. Collected information is covered by the Applicable Military Service
System of Records Notices (SORN) for the Official Military Personnel File or Military Records Jacket.
ROUTINE USE(S): To the lender (Department of Education, U.S. Public Health Service, or other financial institution) you identify so that
the loan amount and status can be verified. The lender returns the completed form to your unit for additional processing. To the Internal
Revenue Service for the purpose of reporting taxable income, and to the credit reporting agencies to assist in the recovery of any improper
payments made toward delinquent debts owed by a beneficiary or former beneficiary. Additional routine uses can be found in the applicable
systems of records notices listed below.
DISCLOSURE: Voluntary. However, if the requested information is not provided, DoD will not be able to verify the loan amount or status
and make the annual payment you are requesting. Your Social Security Number (SSN) is used to ensure accuracy of data involving the
specified individual applicant. If you do not provide your SSN, processing of your application may be delayed.
OFFICIAL MILITARY PERSONNEL FILES:
Air Force: http://dpcld.defense.gov/Privacy/SORNslndex/DOD-wide-SORN-Article-View/Article/569821/f036-af-pc-c/
Army: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/57005 l /a0600-8-104b-ahrc/
Army National Guard: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/ Article/570052/a0600-8-104b-ngb/
Navy: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570310/nO I 070-3/
Marine Corps: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570626/mO I 070-6/

h. With whom will the PII be shared through data exchange, both within your DoD Component and outside your Component? (Check all that apply)

00

D

00

D

D

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Within the DoD Component

Specify.

Other DoD Components

Specify. I

Other Federal Agencies

Specify.

State and Local Agencies

Specify.

Contractor (Name of contractor and describe the language in

the contract that safeguards Pl/. Include whether FAR privacy
clauses, i.e., 52.224-1, Privacy Act Notification, 52.224-2,
Privacy Act, and FAR 39.105 are included in the contract.)

Specify.

00

Other (e.g., commercial providers, colleges).

Specify.

00

Individuals

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I

I

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Services

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DHS, US Coast Guard

I
I

I

Financial Lending Institutions

I. Source of the PII collected is: (Check all that apply and list all information systems if applicable)

D
D

Existing DoD Information Systems

Databases

Commercial Systems

Other Federal Information Systems

J. How will the information be collected?

D
D
D
D
D

D
D

(Check all that apply and list all Official Form Numbers if applicable)

E-mail
Face-to-Face Contact
Fax
Information Sharing - System to System

Other (If Other, enter the information in the box below)

00

D
D
D

Official Form (Enter Form Number(s) in the box below)
Paper
Telephone Interview
Website/E-Form

DD Form 2475 - DoD Educational Loan Repayment Program (LRP) Annual Application
k. Does this DoD Information system or electronic collection require a Privacy Act System of Records Notice (SORN)?
A Privacy Act SORN is required if the information system or electronic collection contains information about U.S. citizens or lawful permanent U.S. residents that
is retrieved by name or other unique identifier. PIA and Privacy Act SORN information must be consistent.
No
� Yes

D

DD FORM 2930, JUN 2017

PREVIOUS EDITION IS OBSOLETE.

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If ''Yes," enter SORN System Identifier

I Military Service Personnel SORNs

SORN Identifier, not the Federal Register {FR) Citation. Consult the DoD Component Privacy Office for additional information or http://dpcld.defense.gov/
Privacy/SORNs/
or

If a SORN has not yet been published in the Federal Register, enter date of submission for approval to Defense Privacy, Civil Liberties, and Transparency
Division (DPCLTD). Consult the DoD Component Privacy Office for this date
If"No," explain why the SORN is not required in accordance with DoD Regulation 5400.11-R: Department of Defense Privacy Program.

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I. What Is the National Archives and Records Administration (NARA) approved, pending or general records schedule (GRS) disposition authority
for the system or for the records maintained In the system?

{1) NARA Job Number or General Records Schedule Authority.
{2) If pending, provide the date the SF-115 was submitted to NARA.

�ee each M1htary Service SORN

!
__________
!

{3) Retention Instructions.

OFFICIAL MILITARY PERSONNEL FILES:
Air Force: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/56982 l /f036-af-pc-c/
Anny: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570051/a0600-8-104b-ahrc/
Anny National Guard: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570052/a0600-8-104b-ngb/
Navy: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570310/nO1070-3/
Marine Corps: http://dpcld.defense.gov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570626/mO I 070-6/
m. What is the authority to collect infonnatlon? A Federal law or Executive Order must authorize the collection and maintenance of a system of
records. For PII not collected or maintained In a system of records, the collection or maintenance of the PII must be necessary to discharge the
requirements of a statue or Executive Order.

(1) If this system has a Privacy Ad. SORN, the authorities in this PIA and the existing Privacy Ad. SORN should be similar.
{2) If a SORN does not apply, cite the authority for this DoD information system or electronic colled.ion to coiled., use, maintain and/or disseminate PII.
{If multiple authorities are cited, provide all that apply).
{a) Cite the specific provisions of the statute and/or EO that authorizes the operation of the system and the collection of PII.
(b) If direct statutory authority or an Executive Order does not exist, indirect statutory authority may be cited if the authority requires the
operation or administration of a program, the execution of which will require the colled.ion and maintenance of a system of records.
(c) If direct or indirect authority does not exist, DoD Components can use their general statutory grants of authority {"internal housekeeping") as
the primary authority. The requirement, directive, or instruction implementing the statute within the DoD Component must be identified.

AU 111uKI 1 Y: I u u .:s.c. 21 71, Education Loan Kepayment Program: Enllsted Members on Active lJuty m :Spec1t1ed Mllltary :Spec1a1t1es;
2173, Education Loan Repayment Program: Commissioned Officers in Specified Health Professions; 16301, Education Loan Repayment
Program: Members of Selected Reserve; 16302, Education Loan Repayment Program: Health Professions Officers Serving in Selected
Reserve with Wartime Critical Medical Skill Shortages; 16303, Loan Repayment Program: Chaplains Serving in the Selected Reserve, and
E.O. 9397. Social Securitv Number (SSN).
n. Does this DoD infonnation system or electronic collection have an active and approved Office of Management and Budget (0MB) Control
Number?

Contad. the Component Information Management Control Officer or DoD Clearance Officer for this information. This number indicates OMS approval to
coiled data from 10 or more members of the public in a 12-month period regardless of form or format.

[!]

Yes

D

No

D Pending

{1) If"Yes," list all applicable 0MB Control Numbers, colledion titles, and expiration dates.
{2) lf"No," explain why 0MB approval is not required in accordance with DoD Manual 8910.01, Volume 2, " DoD Information Coiled.ions Manual:
Procedures for DoD Public Information Collections.•
{3) If "Pending," provide the date for the 60 and/or 30 day notice and the Federal Register citation.

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0MB No. 0704-0152

DD FORM 2930, JUN 2017

PREVIOUS EDITION IS OBSOLETE.

AEM Designer

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