Exhibit 3, 371 FW 3

Instructions: When properly certified, this form is a record serving to indicate that a tenant has been notified of his/her appeal rights. The form is to be completed each time an employee is initially required to reside as a tenant in Government furnished quarters. The original of this form is sent to the Regional Quarters Officer along with other documents necessitated by the action taken, a copy is given to the employee, and a copy is maintained by the supervisor in an appropriate file.
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Employee-Tenant's Name:

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Quarters Location:

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Occupancy Date

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The tenant identified above was furnished information regarding his/her right to appeal a required occupancy determination on_______________ . The tenant received notice of his/her right to appeal rental rates or the adjustment of rental rates for Government furnished quarters in his/her copy of the form DI 1881, Quarters Assignment Agreement, that is certified by and provided to each tenant/occupant or in the DI 1882, Notice of Rental Adjustment, respectively.
 
 

The supervisor's certification below indicates that the tenant received information informing him/her of appeal rights. The tenant's certification acknowledges that such information was received from the supervisor or his/her designee.
 
 

Supervisor's Signature                                                      Date    /    /

Name and Title __________________________________________________

Tenant's Signature                                                           Date    /    /