Dd Form 137 5 – Fill Out and Use This PDF

In 1. ENTITLEMENTS REQUESTED, X and complete as applicable: a. TYPE, BAH, USIP CARD or TRAVEL ALLOWANCE.

b. FIRST APPLICATION? YES or NO. If No, give date of last application (YYYYMMDD).

c. LAST APPLICATION WAS APPROVED or DISAPPROVED.

In 2. MEMBER INFORMATION, enter a. NAME (Last, First, Middle Initial), b. DoD ID NUMBER and c. RANK.

d. Status (X and complete as applicable): Active Duty, National Guard, Army, Navy, Deceased (Date of death) (YYYMMDD), Retired, Reserve, Marine Corps, Air Force or Other (Specify).

i. MARITAL STATUS (X one): SINGLE, SEPARATED, WIDOWED, MARRIED or DIVORCED.

Enter e. COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code) and f. COMPLETE MILITARY ADDRESS (Include assignment: squadron and base).

Enter g. TELEPHONE NUMBERS (Include DSN or Area Code), (1) WORK and (2) HOME, and h. E-MAIL ADDRESS.

In 3. MEMBER'S CHILD, enter a. NAME (Last, First, Middle Initial), b. DOD ID NUMBER and c. DATE OF BIRTH (YYYYMMDD).

d. RELATIONSHIP TO MEMBER (X one): LEGITIMATE CHILD, CHILD BORN OUT OF WEDLOCK, ADOPTED CHILD or STEPCHILD.

Enter e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code). f. HAS CHILD EVER BEEN MARRIED? YES or NO. If Yes, attach a copy of annulment decree, final divorce decree, or death certificate of child's spouse.

In 4. CHILD'S OTHER PARENT(S), enter (1) NAME (Last, First, Middle Initial), (2) RELATIONSHIP TO CHILD and (3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code).

c. IS/ARE OTHER PARENT(S) IN ANY BRANCH OF SERVICE, INCLUDING RESERVE OR NATIONAL GUARD (X one): YES or NO. If Yes, show rank, name, SSN, and military address.

d. Does other parent claim child for Basic Allowance for Housing (BAH), Travel Allowance, or USIP Card (X one): YES or NO. If Yes, explain.

In 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) or STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY.

c. IS RESIDENCE SUBSIDIZED HOUSING? YES or NO. d. DATE CHILD STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD).

6. If child is in hospital or institution: if child is in a hospital or institution, all of the following information must be furnished. Obtain this information from the hospital or institution.

Enter a. Date child entered hospital/institution (YYYYMMDD) and b. Anticipated date of discharge (If known) (YYYYMMDD).

c. Will child return to member's home after discharge? YES or NO. If "NO," explain where child will reside.

When child resides in a hospital or institution and Item 6 is completed, do not complete Item 7, Item 8 or Item 9.

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.

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.

For each ITEM enter (1) PRESENT MONTHLY EXPENSE and (2) TOTAL EXPENSE FOR PAST 12 MONTHS.

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

10. 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.

For each SOURCE enter (1) PRESENT MONTHLY INCOME and (2) TOTAL INCOME FOR PAST 12 MONTHS.

11. Child's employment (Show additional periods of work in the Remarks section.): has child been employed during the past 12 months? YES or NO. If Yes, furnish the following:

(1) NAME OF EMPLOYER, (2) DATE EMPLOYMENT STARTED (YYYYMMDD), (3) DATE EMPLOYMENT ENDED (YYYYMMDD), (4) MONTHLY SALARY (Gross), (5) TYPE OF WORK PERFORMED and (6) REASON EMPLOYMENT ENDED.

d. IS OR WAS CHILD'S JOB CONSIDERED AS BEING A "SHELTERED WORKSHOP" - THAT IS, OPEN ONLY TO DISABLED OR HANDICAPPED PEOPLE? YES or NO. If Yes, and child is currently working, attach a statement from the employer verifying this information.

12. Child's school attendance: has child attended college since age 21? YES or NO. If Yes, furnish the following:

(1) NAME AND ADDRESS OF SCHOOL, (2) (X as applicable) VOCATIONAL or FOR RECEIVING DEGREE, (3) DATES ATTENDED, (4) (X) FULL-TIME or PART-TIME, and (5) CHILD'S MAJOR.

13. Member's contribution: a. Show the total amount the member has contributed to the child's support for each of the past 12 months, (1) Month and year and (2) Amount.

b. MEMBER PROVIDES SUPPORT BY (X one): ALLOTMENT, PERSONAL CHECK, MONEY ORDER or OTHER (Explain).

15. Signatures: read the penalty provisions, sign and date the form, and have it notarized.

Sign (1) SIGNATURE OF PERSON WHO HAS PHYSICAL CUSTODY OF THE CHILD (Can be member or other than member).

Enter (2) RELATIONSHIP TO CHILD and (3) DATE SIGNED (YYYYMMDD).

b. Notary public: subscribed and duly sworn (or affirmed) to before me according to law by the affiant(s).

Sign c. MEMBER (1) SIGNATURE (2) DATE SIGNED (YYYYMMDD).

a. Custodian: the custodian prints name(s) and 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.

DD Form 137-5 is the Dependency Statement - Incapacitated Child Over Age 21. Disclosure is voluntary: however, failure to provide this information will result in a suspension of the dependent entitlements until the member can provide the required certificate.

Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up a material fact, or makes any false, fictitious, or fraudulent statements, shall be fined as provided in Title 18, or imprisoned not more than 5 years, or both (U.S. Code, title 18, section 1001).