DD Form 137-7 Dependency Statement - Ward of Court

CONTROL NUMBER

OMB No. 0730-0014
OMB approval expires

DEPENDENCY STATEMENT - WARD OF A COURT

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), 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

b. FIRST APPLICATION?
USIP

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)

(2) HOME

SINGLE

SEPARATED

MARRIED

DIVORCED

WIDOWED

3. WARD INFORMATION
a. NAME (Last, First, Middle Initial)

b. SSN

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

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4. WARD'S RESIDENCE
a. TYPE OF RESIDENCE (X and complete as applicable)
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)

HOME OR APARTMENT OF MEMBER
HOME OR APARTMENT OF WARD
HOME OR APARTMENT OF FORMER SPOUSE OF MEMBER

STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY

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?

d. DATE WARD BEGAN LIVING AT CURRENT
ADDRESS (YYYYMMDD)

YES

e. DATE WARD BEGAN LIVING WITH PERSON WHO
CURRENTLY HAS PHYSICAL CUSTODY (YYYYMMDD)

NO

5. IF WARD IS A FULL-TIME STUDENT
a. ADDRESS WHERE WARD RESIDES WHILE ATTENDING SCHOOL (Street, Apartment Number, City, State, ZIP Code)

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

STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY

MEMBER'S HOME OR APARTMENT

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)

c. ADDRESS WHERE WARD RESIDES WHILE NOT ATTENDING SCHOOL (Longer than 90 days) (Street, Apartment Number, City, State, ZIP Code)

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

STUDENT DORMITORY OR OTHER ON-CAMPUS FACILITY

MEMBER'S HOME OR APARTMENT

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)

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)

D R A F T
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 TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

ITEM

PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

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

d. FURNITURE/APPLIANCES

e. REPAIRS ON HOME
f. OTHER (Specify)

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

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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.
PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

ITEM

PRESENT MONTHLY TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS

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

a. CLOTHING
b. LAUNDRY AND DRY
CLEANING

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

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

i. SCHOOL EXPENSES (Itemize)

d. VALUE OF USIP CARD
(Verification of amount is
required)
e. PERSONAL INSURANCE
(Specify)

j. OTHER EXPENSES (Itemize)

f. PERSONAL TAXES (Specify)

9. WARD'S SCHOOL EXPENSES
List ward'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
c. SPECIAL FEES
d. ROOM (Rent)

D R A F T

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 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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10.e. WARD'S EXPENSE IN HOSPITAL OR INSTITUTION ARE PAID BY:
PRESENT MONTHLY TOTAL EXPENSE
FOR PAST 12
SOURCE
EXPENSE
MONTHS
U
S
I
P

TOTAL EXPENSE
FOR PAST 12
MONTHS

PRESENT MONTHLY
EXPENSE

SOURCE
(4) STATE OR LOCAL AGENCY
(Name and Address)

(1) CIVILIAN MEDICAL
TREATMENT FACILITY
(CHAMPUS)

C
A (2) MILITARY MEDICAL
R
TREATMENT FACILITY
D
(5) MEMBER

(3) PRIVATE INSURANCE
(Name and Address)

11. WARD'S EMPLOYMENT

(6) OTHER (Explain and give
name and address)

D

R A F T

YES
NO
Has ward been employed since age 21?
If "YES," furnish the following information. Use the Remarks section to continue if necessary.
(1) NAME OF EMPLOYER
a.

(2) DATE EMPLOYMENT STARTED

(5) TYPE OF WORK PERFORMED

(2) DATE EMPLOYMENT STARTED

(5) TYPE OF WORK PERFORMED

(3) DATE ENDED

(4) MONTHLY SALARY (Gross)

(6) REASON EMPLOYMENT ENDED

(1) NAME OF EMPLOYER
c.

(4) MONTHLY SALARY (Gross)

(6) REASON EMPLOYMENT ENDED

(1) NAME OF EMPLOYER
b.

(3) DATE ENDED

(2) DATE EMPLOYMENT STARTED

(5) TYPE OF WORK PERFORMED

(3) DATE ENDED

(4) MONTHLY SALARY (Gross)

(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.

(1) NAME AND ADDRESS OF SCHOOL

(2) (X as applicable)
VOCATIONAL

a.

FOR RECEIVING DEGREE
(3) DATES ATTENDED

(4) (X)

FULL-TIME

(5) WARD'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) WARD'S MAJOR

PART-TIME

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

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)

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TOTAL INCOME
FOR PAST 12
MONTHS

SOURCE

PRESENT MONTHLY
INCOME

TOTAL INCOME
FOR PAST 12
MONTHS

d. SOCIAL SECURITY PAYMENTS,
DISABILITY OR REGULAR
(Specify)
e. SUPPLEMENTAL SECURITY
INCOME (SSI)
f. VETERANS ADMINISTRATION
PAYMENTS (Specify type)

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13. WARD'S INCOME (Continued)
PRESENT MONTHLY
INCOME

SOURCE

TOTAL INCOME
FOR PAST 12
MONTHS

PRESENT MONTHLY
INCOME

SOURCE

TOTAL INCOME
FOR PAST 12
MONTHS

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

g. CONTRIBUTIONS FROM
PERSONS OTHER THAN
h. SCHOLARSHIPS OR
EDUCATIONAL GRANTS

k. OTHER (Specify)

i. TAX REFUNDS (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

b. MEMBER PROVIDES SUPPORT BY (X one)

AMOUNT

ALLOTMENT

MONEY ORDER

PERSONAL CHECK

OTHER (Explain)

MONTH AND YEAR

AMOUNT

15. REMARKS

D

R A F

T

16. SIGNATURES
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.)
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 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).
day of

This

and state (or territory) of

,

, at city (or town) of

, county of

,

.
(Notary)

(Official Seal)

(Official Title)

My commission expires:
c. MEMBER
(1) SIGNATURE

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(2) DATE SIGNED (YYYYMMDD)

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