Dear Mr./Mrs. The enclosed "Former Spouse Information/Application ...

PHS FORMER SPOUSE'S CERTIFICATION OF ELIGIBILITYThis document must be signed by all former spouses of PHS commissioned officers who haveapplied for issuance of Uniformed Services Identification and Privilege Cards (ID card) underthe provisions of the Former Spouses' Protection Act (Public Law 97-252 as amended).I, _______________________, acknowledge that I have been informed of the conditions underwhich I may be issued an ID card and that I must meet the following criteria in order to beeligible for issuance of an ID card based on the service of_______________________, a retiredcommissioned officer of the U.S. Public Health Service, who is my former spouse.1. I was married to the officer named above for at least 20 years.2. My divorce from the officer named above is final and there is no appeal of the divorcepending.3. I have not married since my divorce from the officer named above has become final.4. I do / do not participate in a health insurance program sponsored by myemployer.5. I will notify the Division of Commissioned Corps Officer Support, 1101 WoottonParkway, PL, Ste. 100, Rockville, MD 20852 immediately, in writing, if I remarry orenroll in a health insurance program sponsored by my employer.6. I understand that only the Division of Commissioned Corps Officer Support has theauthority to approve my application for an ID card under the Former Spouses' ProtectionAct.7. I will provide the Division of Commissioned Corps Officer Support with a current addressthrough which I may be contacted during the period that I remain eligible for thesebenefits.8. If I provide false information in making this application I can be prosecuted for fraudagainst the U.S. Government, and may be subject to fine or imprisonment or both.______________________________________Signature_______________________DatePlease return this signed certification to:Division of Commissioned Corps Officer Support, OCCOAttn: DEERS1101 Wootton Parkway, PL, Ste 100Rockville, MD 20857