Fillable INSTRUCTIONS NAVMC 10922 (REV. 4-01) (EF) DEPENDENCY APPLICATION

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INSTRUCTIONS NAVMC 10922 (REV. 4-01) (EF) DEPENDENCY APPLICATION

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DEPENDENCY APPLICATION (1751)
NAVMC 10922 (REV. 4-01) (EF)
(Supersedes all previous editions which are obsolete
and will not be used)
INSTRUCTIONS
WHERE ADDITIONAL SPACE IS
NECESSARY TO COMPLETE ITEMS,
DATE OF APPLICATION
REASON FOR THIS APPLICATION
(CHECK ONE)
CHANGE IN DEPENDENTS
(Check one)
START
CHANGE IN DEPENDENTS
GAIN
SECTION 1.
NAME OF MARINE (Last, first, middle)
SSN
GRADE
TYPE OF SERVICE
ORGANIZATION AND STATION PREPARING THIS APPLICATION
USMC
USMCR
FUTURE ADDRESS AND ETA IF TRANSFER IS ANTICIPATED WITHIN 60 DAYS
UNIT RUC
ECC
DATE OF CURRENT ENLISTMENT/APPOINTMENT
OR DATE REPORTING FOR ACTIVE DUTY
(WHICHEVER IS LATER)
DATE OF LAST DISCHARGE OR DATE OF LAST
RELEASE TO INACTIVE DUTY
SECTION 2 DEPENDENT INFORMATION
NO.
NAME OF DEPENDENT
(Include full given name)
COMPLETE ADDRESS
(Include Zip Code)
RELATIONSHIP DATE OF
BIRTH
(Day, Mo., Year)
DATE ALLOWANCE
CLAIMED FROM (If
previously approved,
give date of approval)
1
2
3
4
5
6
SECTION 3
Furnish the following information concerning custodian of any dependent named above.
DEP
NO
FULL NAME OF CUSTODIAN
RELATIONSHIP TO
DEPENDENT
ADDRESS AND ZIP CODE
INFORMATION CONCERNING PRESENT MARRIAGE
SECTION 4 MARITAL OF SERVICE MEMBER AND SPOUSE AND
INFORMATION REGARDING SUPPORT/PATERNITY
DATE PLACE (County and State) FULL GIVEN NAME OF SPOUSE
HAVE YOU BEEN PREVIOUSLY
MARRIED?
NO
YES
NO OF
TIMES
HAS PRESENT SPOUSE BEEN
PREVIOUSLY MARRIED?
NO
YES
NO OF
TIMES
IF EITHER ANSWER ABOVE IS
INFORMATION CONCERNING DISSOLUTION OF EACH FORMER MARRIAGE OF BOTH YOURSELF AND/OR SPOUSE (Continue on separate sheet if necessary)
FORMER
MARRIAGE OF
NAME OF THE SPOUSE IN
THE DISSOLVED MARRIAGE
DATE OF
DISSOLUTION
Place of dissolution
(County and State)
REASON (Check one)
DEATH ANNULMENT DIVORCE
IS THERE A COURT ORDER OR WRITTEN AGREEMENT IN EFFECT RELATIVE TO SUPPORT/MAINTENANCE/PATERNITY?
IF YES, STATE DATE AND PLACE (county and state) WHERE SUCH ORDER/AGREEMENT WAS ISSUED AND ATTACH A COPY.
NO
YES
YOUR- SPOUSE
ORIGINAL
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I CERTIFY that all the above statements are true to the best of my
knowledge and belief, and I consent to checkage against my pay for any
allowances paid on laws and regulations. I will immediately inform my
Commanding Officer of any change in the number and/or status of my
dependents, whether it be the gain of additional dependents, or the loss
of dependents.
NAVMC 10922 (Rev. 4-01) (EF) Page 2
HAS NATURAL PARENT OTHER THAN CLAIMANT OF CHILD( REN) LISTED EVER BEEN A MEMBER OF ANY
NO
SECTION 5 NATURAL PARENT OF
CHILD IN ARMED FORCES
YES
SECTION 6 SPOUSE IN ARMED FORCES
HAS YOUR SPOUSE EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?
IF YES, COMPLETE THE BLOCKS BELOW.
SSN
GRADE TYPE OF SERVICE BRANCH OF SERVICE INCLUSIVE DATES OF ACTIVE SERVICE BAQ
REGULAR
RESERVE
WITH DEPENDENTS
WITHOUT DEPENDENTS
By signing this form, I hereby authorize release of any information hereon
or obtained as a result of the processing/adjudication of this application, to
my claimed dependents or custodians thereof, to the extent necessary for
the proper adjudication of benefits, entitlements and/or of my legal
obligation to support my dependents.
ORIGINAL
NAME OF MARINE (Last, first, middle)
(Signature and Title of Attesting Officer )
FOR USE BY UNIT DIARY CLERK:
FOR USE BY COMMAND APPROVING AUTHORITY:
SECTION 7 CERTIFICATION
NO.
(Signature of Commanding Officer)
(Typed Name and Grade of Commanding Officer)
(Unit Designation)
DATED
RUC
APPROVED AS
CLAIMED
FORWARDED TO CMC
(CODE MRP-1) FOR
APPROVAL FOR
DEPENDENT NUMBERS
APPROVED FOR
DEPENDENT
NUMBERS:
SECTION 8 APPROVING AUTHORITY
FOR USE BY CMC APPROVING AUTHORITY:
APPROVED FOR CHILD BORN
OUT OF WEDLOCK FOR DEERS
ELIGIBILITY PER MCO
P5512.11. CHECK ONE
CHILD
RESIDES IN
MEMBER'S
HOUSEHOLD
COURT
ORDER
(Recertify annually)
No Court Order
Document Viewed
(Signature of Marine)
(Social Security Number)
(Grade)
Subscribed and sworn
before me this
day of 20
NAVMC 10922 (Rev.5-95) (EF) Page 2
SECTION 8 APPROVING AUTHORITY
Document Viewed
NAVMC 10922 (Rev.5-95) (EF) Page 2
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INSTRUCTIONS NAVMC 10922 (REV. 4-01) (EF) DEPENDENCY APPLICATION

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Completed 16 February 2021

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