Dd Form 137 7 – 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

This form is used to determine Basic Allowance for Housing (BAH), travel allowances, and/or Uniformed Services Identification and Privilege (USIP) card benefits for wards of a court. The member must complete the form as stated in Item 3, sign and date the form, and have it notarized. Answer every question. If any question does not apply, write "NOT APPLICABLE" or "N/A" in that block. Report and verify any income in gross amounts. Verification of income, proof of support and a copy of guardianship documents are required. In the case of a ward who is a full-time student, supporting documentation must include a letter from the accredited college or university verifying the ward's full- time enrollment, documentation of expenses, and any educational assistance that ward may receive. If the ward is incapacitated and over the age of 21, a medical sufficiency statement from a military medical treatment facility is required.

1.ENTITLEMENTS REQUESTED (X and complete as applicable)

2. MEMBER INFORMATION

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

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

3. WARD INFORMATION

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

e.STATUS (X and complete as applicable)

UNMARRIED UNDER 21 YEARS OF AGE (Complete Items 1 - 8 and 13 - 16.)
21-22 YEARS OF AGE AND A FULL-TIME STUDENT (Complete Items 1 - 9 and 12 - 16.)
INCAPACITATED OVER AGE 21 (Complete Items 1 - 8 and 10 - 16.)
HAS WARD EVER BEEN MARRIED? (If "Yes," attach copy of annulment decree, final divorce decree, or death certificate of ward's spouse.)
YES	NO
DD FORM 137-7, JAN 2008	PREVIOUS EDITION IS OBSOLETE.	Page 1 of 5 Pages

Adobe Professional 7.0

4. WARD'S RESIDENCE

a. TYPE OF RESIDENCE (X and complete as applicable)
	HOME OR APARTMENT OF MEMBER		HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
	HOME OR APARTMENT OF WARD
	HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER
			STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
	HOSPITAL OR INSTITUTION		OTHER (Explain)

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 WARD BEGAN LIVING AT CURRENT	e. DATE WARD BEGAN LIVING WITH PERSON WHO
	YES	ADDRESS (YYYYMMDD)	CURRENTLY HAS PHYSICAL CUSTODY (YYYYMMDD)
	NO
5. IF WARD IS A FULL-TIME STUDENT

a.ADDRESS WHERE WARD RESIDES WHILE ATTENDING SCHOOL (Street, Apartment Number, City, State, ZIP Code)

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

	WARD'S OWN HOME OR APARTMENT		STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
	MEMBER'S HOME OR APARTMENT		HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
	HOME OR APARTMENT OF MEMBER'S FORMER SPOUSE
	HOME OR APARTMENT OF MEMBER'S WIDOW OR WIDOWER
			OTHER (Explain)

c.ADDRESS WHERE WARD RESIDES WHILE NOT ATTENDING SCHOOL (Longer than 90 days) (Street, Apartment Number, City, State, ZIP Code)

6. PERSONS LIVING IN HOUSEHOLD WITH WARD

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 ward resides in the member's household or in a dwelling owned by member, use Fair Rental Value (FRV) for dwelling. If ward 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 in the Remarks section.

FAIR RENTAL VALUE (FRV): FRV is a single monthly sum for the entire dwelling where the ward 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			PRESENT MONTHLY	TOTAL EXPENSE FOR		ITEM	PRESENT MONTHLY	TOTAL EXPENSE FOR
				EXPENSE	PAST 12 MONTHS			EXPENSE	PAST 12 MONTHS
a. (X one)
	RENT		FRV				d. FURNITURE/APPLIANCES
	MORTGAGE
	(Specify amount of tax and
	insurance if applicable)						e. REPAIRS ON HOME
	TAX
	INSURANCE						f. OTHER (Specify)

b.FOOD

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

DD FORM 137-7, JAN 2008

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8. WARD'S PERSONAL EXPENSES

List personal expenses for ward. Do not list personal expenses for the member, his or her immediate family, or any other person. List all of the ward's personal expenses regardless of who is paying for them.

	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
					ward's name)
	b. LAUNDRY AND DRY
	CLEANING				h. MONTHLY TRANSPORTA-
					TION PAYMENTS (Include
	c. MEDICAL (Do not include				gas, oil, insurance, repairs,
	expenses paid by insurance,				and public transportation)
	welfare, or Medicare)
					i. SCHOOL EXPENSES (Itemize)

d.VALUE OF USIP CARD (Verification of amount is required)

e.PERSONAL INSURANCE

(Specify)	j. OTHER EXPENSES (Itemize)

f. PERSONAL TAXES (Specify)

9.WARD'S SCHOOL EXPENSES

List ward's school expenses even if covered by scholarship, grant, or other financial aid.

	ITEM	AVERAGE MONTHLY	ITEM	AVERAGE MONTHLY
		EXPENSE		EXPENSE
	a. TUITION		e. BOARD (Food)
			f. OTHER SCHOOL EXPENSES (Specify)

b.BOOKS

c.SPECIAL FEES

d.ROOM (Rent)

10.IF WARD IS IN HOSPITAL OR INSTITUTION (INCAPACITATED)

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

c. WILL WARD RETURN TO MEMBER'S HOME AFTER DISCHARGE? (If "NO," explain where ward will reside)

YES

NO

d. WARD'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
				(10) PERSONAL INSURANCE
	(3) REHABILITATION CLASSES			(Specify)
	OR SERVICES
	(4) SPECIALIZED EQUIPMENT
				(11) OTHER (Specify)
	(5) MEDICAL CARE
	(6) CLOTHING
	(7) LAUNDRY/DRY CLEANING

DD FORM 137-7, JAN 2008

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10.e. WARD'S EXPENSE IN HOSPITAL OR INSTITUTION ARE PAID BY:

	SOURCE	PRESENT MONTHLY	TOTAL EXPENSE	SOURCE	PRESENT MONTHLY	TOTAL EXPENSE
		EXPENSE	FOR PAST 12		EXPENSE	FOR PAST 12
			MONTHS			MONTHS
U (1) CIVILIAN MEDICAL				(4) STATE OR LOCAL AGENCY
				(Name and Address)
S	TREATMENT FACILITY
I

P(CHAMPUS)

	C
	A (2) MILITARY MEDICAL
	R	TREATMENT FACILITY
	D
				(5) MEMBER
	(3) PRIVATE INSURANCE
		(Name and Address)
				(6) OTHER (Explain and give
				name and address)

If "YES," furnish the following information. Use the Remarks section to continue if necessary.

	(1) NAME OF EMPLOYER	(2) DATE EMPLOYMENT STARTED		(3) DATE ENDED	(4) MONTHLY SALARY (Gross)
a.
	(5) TYPE OF WORK PERFORMED		(6) REASON EMPLOYMENT ENDED
	(1) NAME OF EMPLOYER	(2) DATE EMPLOYMENT STARTED		(3) DATE ENDED	(4) MONTHLY SALARY (Gross)
b.
	(5) TYPE OF WORK PERFORMED		(6) REASON EMPLOYMENT ENDED
	(1) NAME OF EMPLOYER	(2) DATE EMPLOYMENT STARTED		(3) DATE ENDED	(4) MONTHLY SALARY (Gross)
c.
	(5) TYPE OF WORK PERFORMED		(6) REASON EMPLOYMENT ENDED

d.IS OR WAS WARD'S JOB CONSIDERED AS BEING A "SHELTERED WORKSHOP" - THAT IS, OPEN ONLY TO DISABLED OR HANDICAPPED PEOPLE? YES (If "YES" and ward is currently working, attach a statement from the employer verifying this information.)

NO

12. WARD'S SCHOOL ATTENDANCE
	Has ward attended college since age 21?		YES		NO	If "YES," furnish the following information.
	(1) NAME AND ADDRESS OF SCHOOL								(2) (X as applicable)
										VOCATIONAL
a.										FOR RECEIVING DEGREE
	(3) DATES ATTENDED					(4) (X)		FULL-TIME	(5) WARD'S MAJOR
								PART-TIME
	(1) NAME AND ADDRESS OF SCHOOL								(2) (X as applicable)
										VOCATIONAL
b.										FOR RECEIVING DEGREE
	(3) DATES ATTENDED					(4) (X)		FULL-TIME	(5) WARD'S MAJOR
								PART-TIME
13. WARD'S INCOME

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

		PRESENT MONTHLY	TOTAL INCOME		PRESENT MONTHLY	TOTAL INCOME
	SOURCE		FOR PAST 12	SOURCE		FOR PAST 12
		INCOME			INCOME
			MONTHS			MONTHS
	a. WAGES, SALARIES, TIPS, OR			d. SOCIAL SECURITY PAYMENTS,
				DISABILITY OR REGULAR
	OTHER CASH GRATUITIES
				(Specify)
	b. INTEREST ON INVESTMENTS,
	BONDS, SAVINGS, TRUST
	FUNDS, ETC.			e. SUPPLEMENTAL SECURITY
	c. INSURANCE OR PUBLIC/			INCOME (SSI)
	GOVERNMENT PENSION
				f. VETERANS ADMINISTRATION
	PAYMENTS, UNEMPLOYMENT
	OR DISABILITY COMPENSATION			PAYMENTS (Specify type)
	(Specify type)

DD FORM 137-7, JAN 2008

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13. WARD'S INCOME (Continued)

		PRESENT MONTHLY	TOTAL INCOME		PRESENT MONTHLY	TOTAL INCOME
	SOURCE		FOR PAST 12	SOURCE		FOR PAST 12
		INCOME			INCOME
			MONTHS			MONTHS
	g. CONTRIBUTIONS FROM			j. STATE OR LOCAL WELFARE AID,
	PERSONS OTHER THAN			INCLUDING AID TO DEPENDENT
				CHILDREN (Include agency and
	h. SCHOLARSHIPS OR			address in Remarks section)
	EDUCATIONAL GRANTS			k. OTHER (Specify)
	i. TAX REFUNDS (Specify)

14. MEMBER'S CONTRIBUTION

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

15. REMARKS

16.SIGNATURES

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.)

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)

My commission expires:

c. MEMBER

DD FORM 137-7, JAN 2008

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