Fillable DEPENDENCY STATEMENT - WARD OF A COURT (Washington Headquarters Services)

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DEPENDENCY STATEMENT - WARD OF A COURT (Washington Headquarters Services)

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DEPENDENCY STATEMENT - WARD OF A COURT
OMB No. 0730-0014
OMB approval expires
May 31, 2021
PRIVACY ACT STATEMENT
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)
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)
SINGLE
MARRIED
SEPARATED
DIVORCED
WIDOWED
3. WARD INFORMATION
a. NAME (Last, First, Middle Initial) b. DoD ID NUMBER c. DATE OF BIRTH
(YYYYMMDD)
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, MAR 2018
PREVIOUS EDITION IS OBSOLETE.
ARMY
MARINE CORPS
NAVY
AIR FORCE
h. E-MAIL ADDRESS
USIP
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.
DD FORM 137-7, MAR 2018
Page 2 of 5 Pages
4. WARD'S RESIDENCE
a. TYPE OF RESIDENCE (X and complete as applicable)
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
HOME OR APARTMENT OF MEMBER
HOME OR APARTMENT OF WARD
HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER
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?
YES
NO
d. DATE WARD BEGAN LIVING AT CURRENT
ADDRESS (YYYYMMDD)
e. DATE WARD BEGAN LIVING WITH PERSON WHO
CURRENTLY HAS PHYSICAL CUSTODY (YYYYMMDD)
5. IF WARD IS A FULL-TIME STUDENT
a. ADDRESS WHERE WARD RESIDES WHILE ATTENDING SCHOOL (Street, Apartment Number, City, State, ZIP Code)
WARD'S OWN HOME OR APARTMENT
MEMBER'S HOME OR APARTMENT
HOME OR APARTMENT OF MEMBER'S FORMER SPOUSE
HOME OR APARTMENT OF MEMBER'S WIDOW OR WIDOWER
b. TYPE OF RESIDENCE (X and complete as applicable)
STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
OTHER (Explain)
c. ADDRESS WHERE WARD RESIDES WHILE NOT ATTENDING SCHOOL (Longer than 90 days) (Street, Apartment Number, City, State, ZIP Code)
WARD'S OWN HOME OR APARTMENT
MEMBER'S HOME OR APARTMENT
HOME OR APARTMENT OF MEMBER'S FORMER SPOUSE
HOME OR APARTMENT OF MEMBER'S WIDOW OR WIDOWER
d. TYPE OF RESIDENCE (X and complete as applicable)
STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
OTHER (Explain)
6. PERSONS LIVING IN HOUSEHOLD WITH WARD
a. NAME (Last, First, Middle Initial) b. AGE
c. MARRIED (X)
YES NO
d. EMPLOYED
HOURS PER WEEK NO (X)
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
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
PRESENT MONTHLY
EXPENSE
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/APPLIANCES
e. REPAIRS ON HOME
f. OTHER (Specify)
TAX
INSURANCE
DD FORM 137-7, MAR 2018
Page 3 of 5 Pages
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
EXPENSE
TOTAL EXPENSE FOR
PAST 12 MONTHS
ITEM
PRESENT MONTHLY
EXPENSE
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
ward's name)
h. MONTHLY TRANSPORTA-
TION PAYMENTS (Include
gas, oil, insurance, repairs,
and public transportation)
i. SCHOOL EXPENSES (Itemize)
j. OTHER EXPENSES (Itemize)
9. WARD'S SCHOOL EXPENSES
List ward's school expenses even if covered by scholarship, grant, or other financial aid.
ITEM
AVERAGE MONTHLY
EXPENSE
a. TUITION
b. BOOKS
c. SPECIAL FEES
d. ROOM (Rent)
ITEM
AVERAGE MONTHLY
EXPENSE
e. BOARD (Food)
f. OTHER SCHOOL EXPENSES (Specify)
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.
a. DATE WARD ENTERED HOSPITAL/INSTITUTION (YYYYMMDD) b. ANTICIPATED DATE OF DISCHARGE (If known)
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
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)
DD FORM 137-7, MAR 2018
Page 4 of 5 Pages
SOURCE
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE
FOR PAST 12
MONTHS
(1) CIVILIAN MEDICAL
TREATMENT FACILITY
(CHAMPUS)
10.e. WARD'S EXPENSE IN HOSPITAL OR INSTITUTION ARE PAID BY:
U
S
I
P
C
A
R
D
(2) MILITARY MEDICAL
TREATMENT FACILITY
(3) PRIVATE INSURANCE
(Name and Address)
SOURCE
PRESENT MONTHLY
EXPENSE
TOTAL EXPENSE
FOR PAST 12
MONTHS
(4) STATE OR LOCAL AGENCY
(Name and Address)
(5) MEMBER
(6) OTHER (Explain and give
name and address)
11. WARD'S EMPLOYMENT
Has ward been employed since age 21?
If "YES," furnish the following information. Use the Remarks section to continue if necessary.
YES NO
a.
b.
c.
(1) NAME OF EMPLOYER (2) DATE EMPLOYMENT STARTED (3) DATE ENDED (4) MONTHLY SALARY (Gross)
(5) TYPE OF WORK PERFORMED (6) REASON EMPLOYMENT ENDED
(1) NAME OF EMPLOYER (2) DATE EMPLOYMENT STARTED (3) DATE ENDED (4) MONTHLY SALARY (Gross)
(5) TYPE OF WORK PERFORMED (6) REASON EMPLOYMENT ENDED
(1) NAME OF EMPLOYER (2) DATE EMPLOYMENT STARTED (3) DATE ENDED (4) MONTHLY SALARY (Gross)
(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.
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) WARD'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) WARD'S MAJOR
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.
SOURCE
PRESENT MONTHLY
INCOME
TOTAL INCOME
FOR PAST 12
MONTHS
a. WAGES, SALARIES, TIPS, OR
OTHER CASH GRATUITIES
d. SOCIAL SECURITY PAYMENTS,
DISABILITY OR REGULAR
(Specify)
b. INTEREST ON INVESTMENTS,
BONDS, SAVINGS, TRUST
FUNDS, ETC.
e. SUPPLEMENTAL SECURITY
INCOME (SSI)
c. INSURANCE OR PUBLIC/
GOVERNMENT PENSION
PAYMENTS, UNEMPLOYMENT
OR DISABILITY COMPENSATION
(Specify type)
f. VETERANS ADMINISTRATION
PAYMENTS (Specify type)
SOURCE
PRESENT MONTHLY
INCOME
TOTAL INCOME
FOR PAST 12
MONTHS
DD FORM 137-7, MAR 2018
Page 5 of 5 Pages
13. WARD'S INCOME (Continued)
SOURCE
PRESENT MONTHLY
INCOME
TOTAL INCOME
FOR PAST 12
MONTHS
g. CONTRIBUTIONS FROM
PERSONS OTHER THAN
i. TAX REFUNDS (Specify)
SOURCE
PRESENT MONTHLY
INCOME
TOTAL INCOME
FOR PAST 12
MONTHS
h. SCHOLARSHIPS OR
EDUCATIONAL GRANTS
j. STATE OR LOCAL WELFARE AID,
INCLUDING AID TO DEPENDENT
CHILDREN (Include agency and
address in Remarks section)
k. OTHER (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.
MONTH AND YEAR AMOUNT MONTH AND YEAR AMOUNT MONTH AND YEAR AMOUNT
ALLOTMENT
PERSONAL CHECK
b. MEMBER PROVIDES SUPPORT BY (X one) MONEY ORDER
OTHER (Explain)
15. REMARKS
16. SIGNATURES
Read the penalty provisions, sign and date the form, and have it notarized.
a. CUSTODIAN
(1) SIGNATURE OF PERSON WHO HAS CUSTODY OF THE WARD (Can be member or other than member) (2) DATE SIGNED (YYYYMMDD)
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)
My commission expires:
c. MEMBER
(1) SIGNATURE (2) 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.)
(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 - WARD OF A COURT (Washington Headquarters Services)

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Completed 19 June 2021

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