DEPENDENCY STATEMENT - INCAPACITATED CHILD OVER AGE 21
OMB No. 0730-0014
OMB approval expires
February 28, 2021
PRIVACY ACT STATEMENT
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)
b. FIRST APPLICATION?
YES (If No, give date of last application)
c. LAST APPLICATION WAS
2. MEMBER INFORMATION
a. NAME (Last, First, Middle Initial) b. DoD ID NUMBER c. RANK
d. STATUS (X and complete as applicable)
DECEASED (Date of death) (YYYYMMDD)
e. COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
f. COMPLETE MILITARY ADDRESS (Include assignment: squadron and base)
g. TELEPHONE NUMBERS (Include DSN or Area Code)
(1) WORK (2) HOME
i. MARITAL STATUS (X one)
DD FORM 137-5, MAR 2018
3. MEMBER'S CHILD
a. NAME (Last, First, Middle Initial) b. DoD ID NUMBER c. DATE OF BIRTH (YYYYMMDD)
e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
d. RELATIONSHIP TO MEMBER (X one)
f. HAS CHILD EVER BEEN MARRIED? (If Yes, attach a copy of annulment
decree, final divorce decree, or death certificate of child's spouse.)
LEGITIMATE CHILD CHILD BORN OUT OF WEDLOCK ADOPTED CHILD STEPCHILD
h. E-MAIL ADDRESS
PREVIOUS EDITION IS OBSOLETE.
The public reporting burden for this collection of information, 0730-0014, is estimated to average 30-60 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 the burden estimate or burden reduction suggestions to
the Department of Defense, Washington Headquarters Services, at email@example.com. 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.
RETURN COMPLETED FORM TO YOUR LOCAL SERVING PERSONNEL/PAYROLL OFFICE.
Page 1 of 5 Pages
Adobe Professional X
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 37 U.S.C., Pay and Allowances of the Uniformed Services; DoD Directive 5154.29, DoD Pay
and Allowances Policy and Procedures; DoD 7000.14-R, DoD Financial Management Manual, Volume 7A,
Military Pay Policy and Procedures – Active
Duty and Reserve Pay; and Joint Travel Regulations (JTR) current edition.
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): To the Treasury Department to provide information on check issues and electronic funds transfers. To Federal, state, and local
governmental agencies in response to an official request for information with respect to law enforcement, investigatory procedures, criminal
prosecution, civil court action and regulatory order. Additional routine uses can be found within the applicable system of records notices, T7344,
Defense Joint Military Pay System-Reserve Component; T7340, Defense Joint Military Pay System-Active Component; and M01040-3, Marine Corps
Manpower Management Information System Records, located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/
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.