DD Form 137-5 Dependency Statement - Incapacitated Child Under Age 21

CONTROL NUMBER

DEPENDENCY STATEMENT INCAPACITATED CHILD OVER AGE 21

OMB No. 0730-0014
OMB approval expires

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, Executive Services Directorate (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
members' 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
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

b. FIRST APPLICATION?
USIP CARD

TRAVEL ALLOWANCE

c. LAST APPLICATION WAS

YES

(If No, give date of last application)

APPROVED

NO

(YYYYMMDD)

DISAPPROVED

2. MEMBER INFORMATION
a. NAME (Last, First, Middle Initial)

b. SSN

c. RANK

d. STATUS (X and complete as applicable)
ACTIVE DUTY

NATIONAL GUARD

ARMY

NAVY

DECEASED (Date of death) (YYYYMMDD)

RETIRED

RESERVE

MARINE CORPS

AIR FORCE

OTHER (Specify)

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

D R A F T

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

g. TELEPHONE NUMBERS (Include DSN or Area Code)
(1) WORK

h. E-MAIL ADDRESS

i. MARITAL STATUS (X one)

(2) HOME

SINGLE

SEPARATED

MARRIED

DIVORCED

WIDOWED

3. MEMBER'S CHILD
a. NAME (Last, First, Middle Initial)

b. SSN

c. DATE OF BIRTH (YYYYMMDD)

d. RELATIONSHIP TO MEMBER (X one)
LEGITIMATE CHILD

CHILD BORN OUT OF WEDLOCK

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

ADOPTED CHILD

STEPCHILD

f. HAS CHILD EVER BEEN MARRIED? (If Yes, attach a copy of annulment
decree, final divorce decree, or death certificate of child's spouse.)
YES
NO

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PREVIOUS EDITION IS OBSOLETE.

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4. CHILD'S OTHER PARENT(S)
a. (1) NAME (Last, First, Middle Initial)

b. (1) NAME (Last, First, Middle Initial)

(2) RELATIONSHIP TO CHILD

(2) RELATIONSHIP TO CHILD

(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

d. DOES OTHER PARENT CLAIM CHILD FOR BASIC ALLOWANCE FOR HOUSING (BAH), TRAVEL ALLOWANCE, OR USIP CARD (X one)
(If Yes, explain.)

NO

YES

NO

D R A F T

5. CHILD'S RESIDENCE
a. TYPE OF RESIDENCE (X and complete as applicable)
HOME OR APARTMENT OF OTHER PARENT

HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)

HOME OR APARTMENT OF MEMBER
HOME OR APARTMENT OF CHILD

HOSPITAL OR INSTITUTION

HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER

OTHER (Explain)

STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
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 CHILD STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD)

YES

NO

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 TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

ITEM

(1) ROOM

(8) EDUCATION

(2) FOOD

(9) TRANSPORTATION

(3) REHABILITATION CLASSES
OR SERVICES

PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

(10) PERSONAL INSURANCE
(Specify)

(4) SPECIALIZED EQUIPMENT
(11) OTHER (Specify)
(5) MEDICAL CARE
(6) CLOTHING
(7) LAUNDRY/DRY CLEANING

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6. IF CHILD IS IN HOSPITAL OR INSTITUTION (Continued)
e. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ARE PAID BY:
SOURCE
(1)
U
S
I
P
C
A
R
D

PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

SOURCE

(a) CIVILIAN MEDICAL
TREATMENT FACILITY
(CHAMPUS)

(3) STATE OR LOCAL AGENCY
(Give name and address
in Remarks section)

(b) MILITARY MEDICAL
TREATMENT FACILITY

(4) MEMBER

(2) PRIVATE INSURANCE
(Give name and address
in Remarks section)

(5) OTHER (Explain and give
name and address in
Remarks section)

7. PERSONS LIVING IN HOUSEHOLD WITH 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.
a. NAME (Last, First, Middle Initial)

b. RELATIONSHIP
TO CHILD

c. AGE

d. MARRIED (X)
YES

D R A F

NO

e. EMPLOYED
HOURS PER WEEK

NO (X)

T

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)
(2)
PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

ITEM

(1)
(2)
PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

a. (X one)
d. FURNITURE AND
APPLIANCES

RENT
FRV
MORTGAGE
(Specify amount of tax and
insurance if applicable)

e. REPAIRS ON HOME

TAX
INSURANCE
b. FOOD

f. OTHER (Itemize in Remarks
section)

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

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)
(2)
PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
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)

ITEM

(1)
(2)
PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

g. PRIVATE AUTO PAYMENTS
(If auto is registered in
child's name)
h. MONTHLY TRANSPORTATION PAYMENTS (Specify
type)

i. SCHOOL EXPENSES
j. OTHER (Specify)

e. PERSONAL INSURANCE
(Specify)
f. PERSONAL TAXES (Specify)

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10. CHILD'S INCOME
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

(1)
PRESENT
MONTHLY
INCOME

(2)
TOTAL INCOME
FOR PAST 12
MONTHS

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)

j. STATE OR LOCAL WELFARE AID,
INCLUDING AID TO DEPENDENT
CHILDREN (Include agency and
address in Remarks section)

d. CONTRIBUTIONS FROM
PERSONS OTHER THAN
MEMBER

f. TAX REFUNDS (Specify)

(2)
TOTAL INCOME
FOR PAST 12
MONTHS

g. SOCIAL SECURITY PAYMENTS,
DISABILITY OR REGULAR (Specify)

a. WAGES, SALARIES, TIPS, OR
OTHER CASH GRATUITIES

e. SCHOLARSHIPS OR
EDUCATIONAL GRANTS

(1)
PRESENT
MONTHLY
INCOME

SOURCE

k. OTHER (Specify)

D R A F T

11. CHILD'S EMPLOYMENT (Show additional periods of work in the Remarks section.)
HAS CHILD BEEN EMPLOYED DURING THE PAST 12 MONTHS?

a.

b.

c.

NO (If Yes, furnish the following:)

YES

(1) NAME OF EMPLOYER

(2) DATE EMPLOYMENT
STARTED (YYYYMMDD)

(3) DATE EMPLOYMENT
ENDED (YYYYMMDD)

(5) TYPE OF WORK PERFORMED

(6) REASON EMPLOYMENT ENDED

(1) NAME OF EMPLOYER

(2) DATE EMPLOYMENT
STARTED (YYYYMMDD)

(5) TYPE OF WORK PERFORMED

(6) REASON EMPLOYMENT ENDED

(1) NAME OF EMPLOYER

(2) DATE EMPLOYMENT
STARTED (YYYYMMDD)

(5) TYPE OF WORK PERFORMED

(6) REASON EMPLOYMENT ENDED

(3) DATE EMPLOYMENT
ENDED (YYYYMMDD)

(3) DATE EMPLOYMENT
ENDED (YYYYMMDD)

(4) MONTHLY SALARY
(Gross)

(4) MONTHLY SALARY
(Gross)

(4) MONTHLY SALARY
(Gross)

d. IS OR WAS CHILD'S JOB CONSIDERED AS BEING A "SHELTERED WORKSHOP" - THAT IS, OPEN ONLY TO DISABLED OR HANDICAPPED PEOPLE?
YES

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:)

(1) NAME AND ADDRESS OF SCHOOL

(2) (X as applicable)
VOCATIONAL

a.

FOR RECEIVING DEGREE
(3) DATES ATTENDED

(4) (X)

FULL-TIME

(5) CHILD'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) CHILD'S MAJOR

PART-TIME

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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

ALLOTMENT

b. MEMBER PROVIDES SUPPORT BY (X one)

(1) MONTH AND YEAR

(2) AMOUNT

PERSONAL CHECK

MONEY ORDER

OTHER (Explain)

14. REMARKS (Use back if necessary)

D R A F T

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.)
15. SIGNATURES
a. CUSTODIAN
(print name(s)) will immediately notify
I/we
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.
(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)

b. NOTARY PUBLIC
Subscribed and duly sworn (or affirmed) to before me according to law by the above named affiant(s).
day of

This

and state (or territory) of

,

, at city (or town) of

, county of

,

.
(Notary)

(Official Seal)

(Official Title)

c. MEMBER
(1) SIGNATURE

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(2) DATE SIGNED (YYYYMMDD)

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