Dd Form 137 4 – Fill Out and Use This PDF

The public reporting burden for this collection of information is estimated to average 1.25 hours 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, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 (0730-0014). 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 ORGANIZATION. RETURN COMPLETED FORM TO YOUR LOCAL SERVING PERSONNEL/PAYROLL OFFICE.

PRIVACY ACT STATEMENT

AUTHORITY: P.L. 93-64; 37 U.S.C., Chapter 7, Section 403; E.O. 9397 (SSN); and DoDFMR 7000.14-R, Vol. 7a, Chapter 26.

PRINCIPAL PURPOSE(S): The information will be used to determine the relationship and dependency of the claimed dependents and determine the member's entitlement to authorized benefits.

ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information

contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD "Blanket Routine Uses" published at the beginning of the DoD compilation of systems of records notices apply.

DISCLOSURE: Voluntary; however, failure to provide this information will result in a suspension of the dependent entitlement until the military member provides the required certification.

INSTRUCTIONS

MALE MEMBER WITH CHILD BORN OUT OF WEDLOCK WHOSE PATERNITY HAS NOT BEEN JUDICIALLY DETERMINED AND WHO DOES NOT RESIDE IN MEMBER'S HOUSEHOLD. Member must complete Items 1 and 2, and sign and date the form. Child's custodian or representative must complete Items 3 through 13, sign and date the form, and have it notarized. CHILD MUST BE MORE THAN 50% DEPENDENT ON MEMBER. If member is deceased, representative of the child must complete this form in its entirety and have the form notarized. Items 5 through 11 must reflect the 12 months prior to the member's death. Report income in GROSS amounts, and attach verification documentation.

NOTE: Answer all questions. If any question does not apply, write "NOT APPLICABLE" or "N/A" in that block. Use the Remarks section when required. Incomplete answers will delay final action on the application.

1.ENTITLEMENTS REQUESTED (X and complete as applicable)

a. TYPE		b. FIRST APPLICATION?				c. LAST APPLICATION WAS
	USIP CARD		YES (If No, give date of last application)				APPROVED
	OTHER (Specify)		NO (YYYYMMDD)				DISAPPROVED

2. MEMBER INFORMATION

e.COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code)

f.COMPLETE MILITARY ADDRESS (Include assignment: squadron and base)

3.	MEMBER'S CHILD
a. NAME (Last, First, Middle Initial)		b. SSN		c. DATE OF BIRTH (YYYYMMDD)
d. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)		e. HAS CHILD EVER BEEN MARRIED? (If Yes, attach a copy of annulment
		decree, final divorce decree, or death certificate of child's spouse.)
			YES
			NO
4.	CHILD'S OTHER BIOLOGICAL PARENT

DD FORM 137-4, JAN 2008

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 4 Pages

Adobe Professional 7.0

4. CHILD'S OTHER BIOLOGICAL PARENT (Continued)

If the mother was married but is now separated, divorced, or widowed, furnish a copy of separation agreement, interlocutory decree, final divorce decree, or death certificate of spouse.

5. CHILD'S RESIDENCE

a.TYPE OF RESIDENCE (X and complete as applicable)

	HOME OR APARTMENT OF OTHER PARENT			HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
	HOME OR APARTMENT OF MEMBER
	HOME OR APARTMENT OF CHILD
				HOSPITAL OR INSTITUTION
	HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER			OTHER (Explain)
	STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
b. OWNER OF RESIDENCE
(1) NAME (Last, First, Middle Initial)		(2) ADDRESS (Street, Apartment Number, City, State, ZIP Code)
c. IS RESIDENCE SUBSIDIZED HOUSING?		d. DATE CHILD STARTED LIVING AT				e. DATE CHILD STARTED LIVING WITH PERSON WHO
	YES	CURRENT ADDRESS (YYYYMMDD)				CURRENTLY HAS PHYSICAL CUSTODY (YYYYMMDD)
	NO

6. PERSONS LIVING IN HOUSEHOLD WITH CHILD

List all persons who live in the household, including claimed child. If employed, show hours per week worked. Continue in Remarks if more space is needed.

7. HOUSEHOLD EXPENSES

List the household expenses for all persons living in the home. If expense was one-time only, such as purchase of a new chair, do not show this as a monthly expense; list it as an expense for the past 12 months. If child resides in the member's household or in a dwelling owned by the member, use Fair Rental Value (FRV) for dwelling. If child does not reside in member's household or in a dwelling owned by member, list actual mortgage, rent, or FRV if dwelling is mortgage-free. If FRV is used, give a brief explanation of how Fair Rental Value was obtained using the Remarks section.

FAIR RENTAL VALUE (FRV): FRV is a single monthly sum for the entire dwelling where the child lives. This sum is an amount the owner can reasonably expect to receive from a stranger to rent the dwelling. FRV will not include food, utilities, furniture, and home repairs, which are listed separately.

		(1)			(2)			(1)	(2)
	ITEM			PRESENT MONTHLY	TOTAL EXPENSE FOR		ITEM	PRESENT MONTHLY	TOTAL EXPENSE FOR
				EXPENSE	PAST 12 MONTHS			EXPENSE	PAST 12 MONTHS
a. (X one)							d. FURNITURE AND
	RENT		FRV				APPLIANCES
	MORTGAGE
	(Specify amount of tax and						e. REPAIRS ON HOME
	insurance if applicable)
	TAX						f. OTHER (Specify)
	INSURANCE

b.FOOD

c.UTILITIES (Heat, power, water, and telephone)

DD FORM 137-4, JAN 2008

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8.CHILD'S PERSONAL EXPENSES

List all of the child's personal expenses regardless of who is paying for them.

	(1)	(2)		(1)	(2)
ITEM	PRESENT MONTHLY	TOTAL EXPENSE FOR	ITEM	PRESENT MONTHLY	TOTAL EXPENSE FOR
	EXPENSE	PAST 12 MONTHS		EXPENSE	PAST 12 MONTHS
a. CLOTHING			g. PRIVATE AUTO PAYMENTS
			(If auto is registered in
			child's name)
b. LAUNDRY AND DRY
CLEANING			h. MONTHLY TRANSPORTA-
			TION PAYMENTS (Specify
c. MEDICAL (Do not include			type)
expenses paid by insurance,
welfare, or Medicare)
			i. SCHOOL EXPENSES (Itemize)
d. VALUE OF USIP CARD
(Verification of amount is
required)
e. PERSONAL INSURANCE			j. OTHER EXPENSES (Itemize)
(Specify)
f. PERSONAL TAXES (Specify)

9. CHILD'S INCOME

All gross income received by or in behalf of the child, whether taxable or nontaxable, and whether received monthly, quarterly, or yearly, must be listed. This includes any income you receive as custodian or administrator for the child. If any income received during the past 12 months was a lump-sum (one-time) payment, be sure to state this. Verification documents are required.

		(1)	(2)		(1)	(2)
	SOURCE	PRESENT	TOTAL INCOME	SOURCE	PRESENT	TOTAL INCOME
		MONTHLY	FOR PAST 12		MONTHLY	FOR PAST 12
		INCOME	MONTHS		INCOME	MONTHS
	a. WAGES, SALARIES, TIPS, OR			g. SOCIAL SECURITY PAYMENTS,
				DISABILITY OR REGULAR (Specify)
	OTHER CASH GRATUITIES
	b. INTEREST ON INVESTMENTS,
	BONDS, SAVINGS, TRUST
	FUNDS, ETC.			h. SUPPLEMENTAL
	c. INSURANCE OR PUBLIC/			SECURITY INCOME (SSI)
	GOVERNMENT PENSION
				i. VETERANS ADMINISTRATION
	PAYMENTS, UNEMPLOYMENT
	OR DISABILITY COMPENSATION			PAYMENTS (Specify type)
	(Specify type)
	d. CONTRIBUTIONS FROM			j. STATE OR LOCAL WELFARE AID,
				INCLUDING AID TO DEPENDENT
	PERSONS OTHER THAN
				CHILDREN (Include agency and
	MEMBER			address in Remarks section)
	e. SCHOLARSHIPS OR			k. OTHER (Specify)
	EDUCATIONAL GRANTS
	f. TAX REFUNDS (Specify)

10. CHILD'S EMPLOYMENT

a. HAS CHILD BEEN EMPLOYED DURING THE PAST 12 MONTHS?		YES		NO (If Yes, furnish the following:)
b. NAME OF EMPLOYER

g. REASON EMPLOYMENT ENDED

11. MEMBER'S CONTRIBUTION

a. SHOW THE TOTAL AMOUNT THE MEMBER HAS CONTRIBUTED TO THE CHILD'S SUPPPORT FOR EACH OF THE PAST 12 MONTHS.

DD FORM 137-4, JAN 2008

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12.REMARKS (Use a separate sheet of paper if necessary)

READ THE PENALTY PROVISIONS, SIGN AND DATE THE FORM, AND HAVE IT NOTARIZED.

NOTE: Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device, a material fact, or makes any false, fictitious, or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry, shall be fined as provided in Title 18, or imprisoned not more than 5 years, or both (U.S. Code, title 18, section 1001). The information provided in this form may be referred to the appropriate Military Service investigative agency.

I make the foregoing claim with full knowledge of the penalties involved for willfully making a false claim. (U.S. Code, title 18, section 287, formerly section 80, provides a penalty as follows: Imprisonment for not more than five years and subject to a fine in the amount provided in this title.)

13.SIGNATURES a. CUSTODIAN

I/we	(print name(s)) will immediately notify

the service concerned of any change in child's financial circumstances, marital status, physical custody, or change in dependency upon the service member as shown in this form.

b. NOTARY PUBLIC

Subscribed and duly sworn (or affirmed) to before me according to law by the above named affiant(s).

This

day of

,

, at city (or town) of

, county of

,

and state (or territory) of

.

(Notary)

(Official Seal)

(Official Title)

DD FORM 137-4, JAN 2008

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