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DEPENDENCY STATEMENT - INCAPACITATED CHILD OVER AGE 21 (Washington Headquarters Services)

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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)
a. TYPE
BAH
TRAVEL ALLOWANCE
b. FIRST APPLICATION?
YES (If No, give date of last application)
NO (YYYYMMDD)
c. LAST APPLICATION WAS
APPROVED
DISAPPROVED
2. MEMBER INFORMATION
a. NAME (Last, First, Middle Initial) b. DoD ID NUMBER c. RANK
d. STATUS (X and complete as applicable)
ACTIVE DUTY
RETIRED
NATIONAL GUARD
RESERVE
DECEASED (Date of death) (YYYYMMDD)
OTHER (Specify)
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)
SINGLE
MARRIED
SEPARATED
DIVORCED
WIDOWED
DD FORM 137-5, MAR 2018
ARMY
MARINE CORPS
NAVY
AIR FORCE
USIP CARD
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)
YES
NO
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PREVIOUS EDITION IS OBSOLETE.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 whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.
INSTRUCTIONS
4. CHILD'S OTHER PARENT(S)
(1) NAME (Last, First, Middle Initial)
(2) RELATIONSHIP TO CHILD
a. (1) NAME (Last, First, Middle Initial)
(2) RELATIONSHIP TO CHILD
b.
DD FORM 137-5, MAR 2018
Page 2 of 5 Pages
(3) COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code) (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)
(If Yes, show rank, name, SSN, and military address.)
YES NO
d. DOES OTHER PARENT CLAIM CHILD FOR BASIC ALLOWANCE FOR HOUSING (BAH), TRAVEL ALLOWANCE, OR USIP CARD (X one)
(If Yes, explain.)
YES NO
5. CHILD'S RESIDENCE
a. TYPE OF RESIDENCE (X and complete as applicable)
STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
HOSPITAL OR INSTITUTION
HOME OR APARTMENT OF OTHER PARENT
HOME OR APARTMENT OF MEMBER
HOME OR APARTMENT OF CHILD
HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER
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?
YES
NO
d. DATE CHILD STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD)
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
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.
a. DATE CHILD ENTERED HOSPITAL/INSTITUTION (YYYYMMDD) b. ANTICIPATED DATE OF DISCHARGE (If known)
c. WILL CHILD RETURN TO MEMBER'S HOME AFTER DISCHARGE? (If "NO," explain where child will reside) YES NO
d. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION
ITEM
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
(1) ROOM
(2) FOOD
(3) REHABILITATION CLASSES
OR SERVICES
(4) SPECIALIZED EQUIPMENT
(5) MEDICAL CARE
(6) CLOTHING
(7) LAUNDRY/DRY CLEANING
(8) EDUCATION
(9) TRANSPORTATION
(10) PERSONAL INSURANCE
(Specify)
(11) OTHER (Specify)
e. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ARE PAID BY:
SOURCE
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
SOURCE
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
(1)
U
S
I
P
C
A
R
D
6. IF CHILD IS IN HOSPITAL OR INSTITUTION (Continued)
(a) CIVILIAN MEDICAL
TREATMENT FACILITY
(CHAMPUS)
(b) MILITARY MEDICAL
TREATMENT FACILITY
(2) PRIVATE INSURANCE
(Give name and address
in Remarks section)
(3) STATE OR LOCAL AGENCY
(Give name and address
in Remarks section)
(4) MEMBER
(5) OTHER (Explain and give
name and address in
Remarks section)
7. PERSONS LIVING IN HOUSEHOLD WITH CHILD
a. NAME (Last, First, Middle Initial) c. AGE
d. MARRIED (X)
YES NO
e. EMPLOYED
HOURS PER WEEK NO (X)
b. RELATIONSHIP
TO 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)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
(1)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
a. (X one)
MORTGAGE
(Specify amount of tax and
insurance if applicable)
RENT FRV
b. FOOD
c. UTILITIES (Heat, power,
water, and telephone)
d. FURNITURE AND
APPLIANCES
e. REPAIRS ON HOME
f. OTHER (Itemize in Remarks
section)
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.
ITEM
(1)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
(1)
PRESENT MONTHLY
EXPENSE
(2)
TOTAL EXPENSE FOR
PAST 12 MONTHS
a. CLOTHING
b. LAUNDRY AND DRY
CLEANING
c. MEDICAL (Do not include
expenses paid by insurance,
welfare, or Medicare)
d. VALUE OF USIP CARD
(Verification of amount is
required)
e. PERSONAL INSURANCE
(Specify)
f. PERSONAL TAXES (Specify)
g. PRIVATE AUTO PAYMENTS
(If auto is registered in
child's name)
h. MONTHLY TRANSPORTA-
TION PAYMENTS (Specify
type)
i. SCHOOL EXPENSES
j. OTHER (Specify)
TAX
INSURANCE
DD FORM 137-5, MAR 2018
Page 3 of 5 Pages
DD FORM 137-5, MAR 2018
Page 4 of 5 Pages
(1)
PRESENT
MONTHLY
INCOME
(2)
TOTAL INCOME
FOR PAST 12
MONTHS
a. WAGES, SALARIES, TIPS, OR
OTHER CASH GRATUITIES
g. SOCIAL SECURITY PAYMENTS,
DISABILITY OR REGULAR (Specify)
b. INTEREST ON INVESTMENTS,
BONDS, SAVINGS, TRUST
FUNDS, ETC.
h. SUPPLEMENTAL
SECURITY INCOME (SSI)
c. INSURANCE OR PUBLIC/
GOVERNMENT PENSION
PAYMENTS, UNEMPLOYMENT
OR DISABILITY COMPENSATION
(Specify type)
i. VETERANS ADMINISTRATION
PAYMENTS (Specify type)
SOURCE
(1)
PRESENT
MONTHLY
INCOME
(2)
TOTAL INCOME
FOR PAST 12
MONTHS
d. CONTRIBUTIONS FROM
PERSONS OTHER THAN
MEMBER
f. TAX REFUNDS (Specify)
k. OTHER (Specify)
e. SCHOLARSHIPS OR
EDUCATIONAL GRANTS
j. STATE OR LOCAL WELFARE AID,
INCLUDING AID TO DEPENDENT
CHILDREN (Include agency and
address in Remarks section)
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.
SOURCE
10. CHILD'S INCOME
11. CHILD'S EMPLOYMENT (Show additional periods of work in the Remarks section.)
YES HAS CHILD BEEN EMPLOYED DURING THE PAST 12 MONTHS? 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 (6) REASON EMPLOYMENT ENDED
a.
(1) NAME OF EMPLOYER (2) DATE EMPLOYMENT
STARTED (YYYYMMDD)
(3) DATE EMPLOYMENT
ENDED (YYYYMMDD)
(4) MONTHLY SALARY
(Gross)
(5) TYPE OF WORK PERFORMED (6) REASON EMPLOYMENT ENDED
b.
(1) NAME OF EMPLOYER (2) DATE EMPLOYMENT
STARTED (YYYYMMDD)
(3) DATE EMPLOYMENT
ENDED (YYYYMMDD)
(4) MONTHLY SALARY
(Gross)
(5) TYPE OF WORK PERFORMED (6) REASON EMPLOYMENT ENDED
c.
YES
d. IS OR WAS CHILD'S JOB CONSIDERED AS BEING A "SHELTERED WORKSHOP" - THAT IS, OPEN ONLY TO DISABLED OR HANDICAPPED PEOPLE?
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 NO
(If Yes, furnish the following:)
a.
b.
(1) NAME AND ADDRESS OF SCHOOL
(2) (X as applicable)
VOCATIONAL
FOR RECEIVING DEGREE
(3) DATES ATTENDED
(4) (X)
FULL-TIME
PART-TIME
(5) CHILD'S MAJOR
(1) NAME AND ADDRESS OF SCHOOL
(2) (X as applicable)
VOCATIONAL
FOR RECEIVING DEGREE
(3) DATES ATTENDED
(4) (X)
FULL-TIME
PART-TIME
(5) CHILD'S MAJOR
DD FORM 137-5, MAR 2018
Page 5 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
ALLOTMENT PERSONAL CHECK
b. MEMBER PROVIDES SUPPORT BY (X one)
MONEY ORDER
OTHER (Explain)
14. REMARKS (Use back if necessary)
READ THE PENALTY PROVISIONS, SIGN AND DATE THE FORM, AND HAVE IT NOTARIZED.
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 Title)(Official Seal)
c. MEMBER
(1) SIGNATURE (2) DATE SIGNED (YYYYMMDD)
(1) SIGNATURE OF PERSON WHO HAS PHYSICAL CUSTODY OF THE CHILD (Can be member
or other than member)
(2) RELATIONSHIP TO CHILD (3) DATE SIGNED
(YYYYMMDD)
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
(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.
I/we
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DEPENDENCY STATEMENT - INCAPACITATED CHILD OVER AGE 21 (Washington Headquarters Services)

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Completed 18 February 2021

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