Form DD1199 Pentagon Reservation Parking Permit Application

CUI (when filled in)
(Updated YYYYMMDD)
OMB No. 0704-0395
OMB approval expires
YYYYMMDD

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. DOD ID NO.

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)
a. PENTAGON

b. MARK CENTER

c. SUFFOLK
d. OTHER (Specify)
10. WORK TELEPHONE NUMBER (Include area code)

9. ROOM NUMBER

13. AGENCY/DIVISION

12. DEPARTMENT (X one)
a. ARMY

11. HOME ZIP CODE

b. AIR FORCE

c. NAVY

DRAFT

e. OFFICE OF THE SECRETARY OF DEFENSE
h. OTHER (Specify)
14. VEHICLE TAGS
a.(1) LICENSE PLATE (2) STATE
NUMBER

d. DEPARTMENT OF DEFENSE
f. SPACE FORCE

b.(1) LICENSE PLATE (2) STATE
NUMBER

g. USMC

c.(1) LICENSE PLATE (2) STATE
NUMBER

d.(1) LICENSE PLATE (2) STATE
NUMBER

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 b. DATE (YYYYMMDD)

20.a. CPR/AUTHORIZING OFFICIAL SIGNATURE

b. DATE (YYYYMMDD)

FOR OFFICE USE ONLY
21. PERMIT TYPE

22. PERMIT NUMBER

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

DD FORM 1199, APRIL 2024
PREVIOUS EDITION IS OBSOLETE.

25. PROCESSOR SIGNATURE

CUI (when filled in)

23. PERMIT EXPIRATION DATE (YYYYMMDD)

26. SIGNATURE DATE
(YYYYMMDD)

Controlled by: WHS
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: [email protected]

Reset

CUI (when filled in)

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, Executive Services
Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0395). 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. 113, Secretary of Defense; 10 U.S.C. 2674, Operation and Control of Pentagon Reservation and Defense
Facilities in National Capital Region; DoD Directive 5105.53, Director of Administration and Management (DA&M); DoD Directive
5110.04, Washington Headquarters Services (WHS); Administrative Instruction 88, Pentagon Reservation Vehicle Parking Program.
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): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as
amended, the records contained herein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)
(3) as listed in the applicable system of records notice located at:
https://www.federalregister.gov/documents/2024/12/23/2024-30615/privacy-act-of-1974-system-of-records

DRAFT

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), APRIL 2024

CUI (when filled in)