DD Form 137-6 Dependency Statement - Full Time Student 21-22 Years of

CONTROL NUMBER

DEPENDENCY STATEMENT FULL TIME STUDENT
21 - 22 YEARS OF AGE

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
This form is used to determine Basic Allowance for Housing (BAH) eligibility for students 21 - 22 years of age. Member completes Items 1 and 15.
Member, student, or student's custodian completes Items 2 through 14, and has the form 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. A verification of enrollment at an institution
of higher learning is required. Verification must be on official school letterhead, and include the school's name and address, the student's status
(full-time or part-time), the projected graduation date, and the school's official stamp. Proof of member's contribution (dependent support allotments,
cancelled checks, copies of money order receipts, etc., is required.
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. STUDENT
a. NAME (Last, First, Middle Initial)

b. SSN

c. DATE OF BIRTH (YYYYMMDD)

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

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

4. SCHOOL INFORMATION
a. NAME OF SCHOOL

b. COMPLETE SCHOOL ADDRESS (Street, City, State, ZIP Code)

c. X ALL MONTHS STUDENT ATTENDS SCHOOL
YEAR

JAN

FEB

MAR

APR

d. DOES STUDENT ATTEND SCHOOL ON A FULL-TIME BASIS?
YES

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

e. MONTH AND YEAR STUDENT EXPECTS TO GRADUATE

NO

DD FORM 137-6, 20070723 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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5. STUDENT'S OTHER PARENT(S)
a. (1) NAME (Last, First, Middle Initial)

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

(2) RELATIONSHIP TO STUDENT

(2) RELATIONSHIP TO STUDENT

(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 STUDENT FOR BASIC ALLOWANCE FOR HOUSING (BAH), TRAVEL ALLOWANCE, OR USIP CARD (X one)
(If Yes, explain.)

YES

NO

6. STUDENT'S RESIDENCE
a. ADDRESS WHERE STUDENT RESIDES WHILE ATTENDING SCHOOL (Street, Apartment Number, City, State, ZIP Code)

b. TYPE OF RESIDENCE (X and complete as applicable)
STUDENT'S OWN HOME OR APARTMENT

HOME OR APARTMENT OF OTHER PARENT

HOME OR APARTMENT OF MEMBER

HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)

HOME OR APARTMENT OF MEMBER'S FORMER SPOUSE
HOME OR APARTMENT OF MEMBER'S WIDOW OR WIDOWER

OTHER (Explain)

STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY
c. ADDRESS WHERE STUDENT RESIDES, IN EXCESS OF 90 DAYS, WHILE NOT ATTENDING SCHOOL (Street, Apartment Number, City, State, ZIP Code)

d. TYPE OF RESIDENCE (X and complete as applicable)
STUDENT'S OWN HOME OR APARTMENT

HOME OR APARTMENT OF OTHER PARENT

HOME OR APARTMENT OF MEMBER

HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)

HOME OR APARTMENT OF MEMBER'S FORMER SPOUSE
HOME OR APARTMENT OF MEMBER'S WIDOW OR WIDOWER

OTHER (Explain)

STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY

7. PERSONS LIVING IN HOUSEHOLD WITH STUDENT
List all persons who live in the household, including claimed student. If employed, show hours per week worked. Continue in Remarks if more
space is needed.
a. NAME (Last, First, Middle Initial)

b. RELATIONSHIP
TO STUDENT

c. AGE

d. MARRIED (X)
YES

NO

e. EMPLOYED
HOURS PER WEEK

NO (X)

D R A F T
8. 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 student resides in the member's household or in a dwelling owned by the member,
use Fair Rental Value (FRV) for dwelling. If student 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 student 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

a. (X one)
RENT
FRV
MORTGAGE
(Specify amount of tax and
insurance if applicable)

ITEM

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

d. FURNITURE AND
APPLIANCES

e. REPAIRS ON HOME

TAX
INSURANCE
b. FOOD
c. UTILITIES (Heat, power,
water, and telephone)

DD FORM 137-6, 20070723 DRAFT

f. OTHER (Itemize in Remarks
section)

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9. STUDENT'S PERSONAL EXPENSES.

List all of the student's personal expenses regardless of who is paying for them.
AVERAGE MONTHLY
EXPENSE

ITEM

AVERAGE MONTHLY
EXPENSE

ITEM
f. PERSONAL TAXES (Specify)

a. CLOTHING
b. LAUNDRY AND DRY CLEANING

g. PRIVATE AUTO PAYMENTS (If auto is
registered in student's name)

c. MEDICAL (Do not include expenses paid
by insurance, welfare, or Medicare)

h. MONTHLY TRANSPORTATION PAYMENTS
(Include gas, oil, insurance, repairs, and
public transportation)

d. VALUE OF USIP CARD (Verification of
amount is required)

i. OTHER (Specify)

e. PERSONAL INSURANCE (Specify)

10. STUDENT'S SCHOOL EXPENSES.

List all of the student's school expenses even if covered by scholarship, grant, or other financial aid.
AVERAGE MONTHLY
EXPENSE

ITEM
a. TUITION

AVERAGE MONTHLY
EXPENSE

ITEM
e. BOARD (Food)
f. OTHER SCHOOL EXPENSES (Specify)

b. BOOKS

D R A F T

c. SPECIAL FEES
d. ROOM (Rent)

11. STUDENT'S INCOME
All gross income received by or in behalf of the student, 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 student. 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.
(1)
PRESENT
MONTHLY
INCOME

SOURCE

(2)
TOTAL INCOME
FOR PAST 12
MONTHS

(1)
PRESENT
MONTHLY
INCOME

SOURCE

(2)
TOTAL INCOME
FOR PAST 12
MONTHS

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

a. WAGES, SALARIES, TIPS, OR
OTHER CASH GRATUITIES
b. INTEREST ON INVESTMENTS,
BONDS, SAVINGS, TRUST
FUNDS, ETC.
c. INSURANCE OR PUBLIC/
GOVERNMENT PENSION
PAYMENTS, UNEMPLOYMENT
OR DISABILITY COMPENSATION
(Specify type)

h. SUPPLEMENTAL
SECURITY INCOME (SSI)
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

k. OTHER (Specify)

e. SCHOLARSHIPS OR
EDUCATIONAL GRANTS
f. TAX REFUNDS (Specify)

12. STUDENT'S EMPLOYMENT
a. HAS STUDENT BEEN EMPLOYED DURING THE PAST 12 MONTHS?
b. NAME OF EMPLOYER

YES

c. DATE EMPLOYMENT
STARTED (YYYYMMDD)

NO (If Yes, furnish the following:)
d. DATE EMPLOYMENT
ENDED (YYYYMMDD)

e. MONTHLY SALARY
(Gross)

g. REASON EMPLOYMENT ENDED

f. TYPE OF WORK PERFORMED

13. MEMBER'S CONTRIBUTION
a. SHOW THE TOTAL AMOUNT THE MEMBER HAS CONTRIBUTED TO THE STUDENT'S SUPPPORT FOR EACH OF THE PAST 12 MONTHS.
(1) MONTH AND YEAR

(2) AMOUNT

b. MEMBER PROVIDES SUPPORT BY (X one)

(1) MONTH AND YEAR

ALLOTMENT

(2) AMOUNT

(1) MONTH AND YEAR

PERSONAL CHECK

(2) AMOUNT

MONEY ORDER

OTHER (Explain)

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14. REMARKS (Use a separate sheet of paper 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. MEMBER, STUDENT, OR CUSTODIAN OF STUDENT
(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

(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).
day of

This

and state (or territory) of

,

, at city (or town) of

, county of

,

.
(Notary)

(Official Seal)

(Official Title)

c. MEMBER
(1) SIGNATURE

DD FORM 137-6, 20070723 DRAFT

(2) DATE SIGNED (YYYYMMDD)

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