Dd Form 137 5 – Fill Out and Use

DEPENDENCY STATEMENT -	CONTROL NUMBER	OMB No. 0730-0014
		OMB approval expires
INCAPACITATED CHILD OVER AGE 21
		Jul 31, 2017

The public reporting burden for this collection of information is estimated to average 50 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 (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: 5 U.S.C. Section 301; Departmental Regulations; 37 U.S.C. Section 404, Travel and Transportation Allowances general; DoD Directive 5154.29, DoD Pay and Allowances Policy and Procedures, Joint Travel Regulation, Chapter 10; and E.O. 9397 (SSN), as amended.

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

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

contained therein may specifically be disclosed outside of DoD as a routine use pursuant to 5. U.S.C. 552a(b)(3) as follows: The DoD Blanket Routine Uses published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply.

Applicable SORNs: DJMS-AC/RC, DRAS: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570191/t7340.aspx http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570195/t7344.aspx http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570196/t7347b.aspx

USMC MCTFS: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570625/m01040-3.aspx

DISCLOSURE: Voluntary: however, failure to provide this information will result in a suspension of the dependent entitlements until the member can provide the required certificate.

INSTRUCTIONS

The member must complete the form in its entirety, sign and date the form, and have it notarized. If the child resides alone or with someone other than the member, the member completes Items 1, 2, and 16, signs and dates the form, and the child or child's representative completes Items 3 through 15, signs and dates the form, and has it notarized. If the member is deceased, the child or child's representative completes the form in its entirety, signs and dates the form, and has it notarized. Information furnished must reflect the 12 months prior to member's death. Verification of income is required.

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
	BAH		USIP CARD		YES (If No, give date of last application)				APPROVED
	TRAVEL ALLOWANCE				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

	d. RELATIONSHIP TO MEMBER (X one)
		LEGITIMATE CHILD					CHILD BORN OUT OF WEDLOCK		ADOPTED CHILD		STEPCHILD
	e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)							f. 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
	DD FORM 137-5,						PREVIOUS EDITION IS OBSOLETE.				Page 1 of 5 Pages
			)(% 201
											Adobe Professional X

4. CHILD'S OTHER PARENT(S)

a.	(1) NAME (Last, First, Middle Initial)	b.	(1) NAME (Last, First, Middle Initial)
(2) RELATIONSHIP TO CHILD		(2) RELATIONSHIP TO CHILD
(3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)		(3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)

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 CURRENT ADDRESS (YYYYMMDD)
	YES		NO

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.

d. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION

	ITEM	PRESENT MONTHLY	TOTAL EXPENSE FOR		ITEM	PRESENT MONTHLY	TOTAL EXPENSE FOR
		EXPENSE	PAST 12 MONTHS			EXPENSE	PAST 12 MONTHS
	(1) ROOM				(8) EDUCATION
	(2) FOOD				(9) TRANSPORTATION
	(3) REHABILITATION CLASSES				(10) PERSONAL INSURANCE
					(Specify)
	OR SERVICES
	(4) SPECIALIZED EQUIPMENT
					(11) OTHER (Specify)

(5)MEDICAL CARE

(6)CLOTHING

(7)LAUNDRY/DRY CLEANING

DD FORM 137-5, )(% 201

Page 2 of 5 Pages

6. IF CHILD IS IN HOSPITAL OR INSTITUTION (Continued)

e. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ARE PAID BY:

		SOURCE	PRESENT MONTHLY	TOTAL EXPENSE FOR	SOURCE	PRESENT MONTHLY	TOTAL EXPENSE FOR
			EXPENSE	PAST 12 MONTHS		EXPENSE	PAST 12 MONTHS
(1)		(a) CIVILIAN MEDICAL			(3) STATE OR LOCAL AGENCY
U		TREATMENT FACILITY			(Give name and address
S
I		(CHAMPUS)			in Remarks section)
P
C		(b) MILITARY MEDICAL			(4) MEMBER
A		TREATMENT FACILITY
R
D
(2) PRIVATE INSURANCE					(5) OTHER (Explain and give
	(Give name and address				name and address in
	in Remarks section)				Remarks section)

7. PERSONS LIVING IN HOUSEHOLD WITH CHILD

When child resides in a hospital or institution and Item 6 is completed, do not complete this item. 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.

8. HOUSEHOLD EXPENSES

When child resides in a hospital or institution and Item 6 is completed, do not complete this item. 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.

	ITEM			(1)	(2)	ITEM	(1)	(2)
				PRESENT MONTHLY	TOTAL EXPENSE FOR		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
	insurance if applicable)
	TAX					e. REPAIRS ON HOME
	INSURANCE
b. FOOD						f. OTHER (Itemize in Remarks
c. UTILITIES (Heat, power,
						section)
water, and telephone)

9.CHILD'S PERSONAL EXPENSES

When child resides in a hospital or institution and Item 6 is completed, do not complete this item. 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
b. LAUNDRY AND DRY				child's name)
CLEANING
				h. MONTHLY TRANSPORTA-
c. MEDICAL (Do not include				TION PAYMENTS (Specify
expenses paid by insurance,				type)
welfare, or Medicare)
d. VALUE OF USIP CARD				i. SCHOOL EXPENSES
(Verification of amount is
required)				j. OTHER (Specify)

e.PERSONAL INSURANCE

(Specify)

f.PERSONAL TAXES (Specify)

DD FORM 137-5, FEB 2016

Page 3 of 5 Pages

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

(2) AMOUNT

(1) MONTH AND YEAR

(2) AMOUNT

(1) MONTH AND YEAR

(2) AMOUNT

b. MEMBER PROVIDES SUPPORT BY (X one)

ALLOTMENT

PERSONAL CHECK

MONEY ORDER

OTHER (Explain)

14. REMARKS (Use back 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.)

15.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 137-5, FEB 2016

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