Form NAVCRUIT 1130/13 NAVCRUIT 1130/13 Enlistee Financial Statement

OMB NO: 0703-0020

Expires:

ENLISTEE FINANCIAL STATEMENT

The public reporting burden for this collection of information is estimated to average 33 minutes per response including the time for reviewing instructions, searching existing date 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 Department of Defense, Washington Headquarters Services, Executive Services Directorate (0703-0020), 1155 Defense Pentagon, Washington, DC 20301-1155. Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR ENLISTEE FINANCIAL STATEMENT TO THE ABOVE ADDRESS.

PRIVACY ACT STATEMENT AUTHORITY 5 U.S.C. 301 Department Regulations; 10 U.S.C. Sections 503, 504, 508 and 510 and e.o. 9397 Principal Purpose or Purposes. The information is to determine your eligibility for enlistment in the armed forces of the United States. The information requested constitutes the minimum required to determine your present financial status. Your answers will be used to determine demonstrated ability to financially manage your household and whether or not should you be accepted and subsequently enlisted, your military pay and associated benefits would be sufficient to allow you to provide adequate financial support to your dependents without causing personal hardship. Routine Uses. The information provided by you on this document is FOR OFFICIAL USE ONLY and will be maintained and used in strict confidence by Navy Officers and employees of the Navy Recruiting Command to determine eligibility. Whether Disclosure is Mandatory or Voluntary and Effect on Individual of Not Providing Information. The information is voluntary, however failure to answer completely any of the questions or to provide the information requested in this form may result in an inability to process you for enlistment. Applicant’s initials or signature:

This statement is used only by authorized U.S. Navy personnel and shall be completed by all applicants with dependents enlisting or reenlisting in the Regular Navy/Navy Reserve. It must be completed in the applicant's handwriting. Applicants in DEP over 90 days are required to complete an updated statement prior to shipping to RTC Applicants who acquire dependents while in DEP shall complete this statement prior to shipping to RTC. The signature of the spouse is mandatory unless the spouse resides outside the local recruiting area. Comments of recruiting service personnel will NOT be recorded on this form.

1. APPLICANT'S NAME (LAST, FIRST, MI)

2. SSN:

3. ELIGIBLE PAYGRADE:

4.DATE OF STATEMENT (YYMMDD):

5. APPLICANT'S CURRENT EMPLOYER

5a. NET MONTHLY PAY:

6. NUMBER OF DEPENDENTS (INCLUDE AGES AND UNBORN CHILD, IF PREGNANT)

7. SPOUSE'S MONTHLY NET PAY (TAKE HOME):

8. NUMBER OF SPOUSE DEPENDENTS NOT IN ITEM 6:

9. OTHER APPLICANT/FAMILY INCOME (list source and monthly amount)

10. HOUSING: _____OWN _____ BUYING _____ RENTING _____ OTHER EXPLAIN

10a. Housing monthly cost:

11. Do you have a savings account? [ ] YES [ ] NO Do you have a checking account? [ ] YES [ ] NO Current Balance: $__________________ Current Balance: $__________________

12. Have you ever filed for bankruptcy? [ ] YES [ ] NO If yes, explain a. Have you ever been late on any payment more than 30 days? [ ] YES [ ] NO If yes, explain b. Do you have any liens or judgments pending against you? [ ] YES [ ] NO If yes, explain

13. ESTIMATED MONTHLY NAVY INCOME (Base Pay) Estimated monthly income, prior to taxes and deductions, shall be calculated based on the current Defense Finance and Accounting Service (DFAS) Basic Pay Table found at http://www.dod.mil/dfas/money/milpay/pay/ For Official Use Only When Filled In Total estimated Navy Pay (based on gross basic pay for enlistment paygrade): $__________

ENLISTEE FINANCIAL STATEMENT

14. Monthly Recurring Debt:

CATEGORY

CREDITOR

TOTAL AMOUNT OWED

MONTHLY PAYMENT

AUTOMOBILE (1)

CREDIT CARD (1)

CREDIT CARD (2)

CREDIT CARD (3)

CREDIT CARD (4)

CREDIT CARD (5)

BANK LOAN(1)

BANK LOAN(2)

CHILD SUPPORT/ALIMONY

OTHER CREDIT DEBT

TOTALS

14a.

15. Monthly Living Expenses:

EXPENSE CATEGORY

MONTHLY EXPENDITURE

REMARKS

FOOD

CLOTHING

UTILITIES (ELECTRIC/GAS/WATER/ETC)

INSURANCE (AUTO/HOME/LIFE/HEALTH/ETC)

CHILD CARE

PHONE

CELLULAR SERVICE

TELEVISION/CABLE/SATELLITE SERVICE

ENTERTAINMENT

MISCELLANEOUS FEES FOR SERVICES

MEDICAL CARE AND PRESCRIPTIONS

OTHER EXPENSE (TYPE: )

TOTAL FROM ITEM 14 (BLOCK 14a)

TOTAL MONTHLY LIVING EXPENSES

15a.

16. Applicant's Remarks: (if additional space is required, continue on separate sheet of paper.)

17. Financial Stability Calculations: Estimated Net Family Income (Add blocks 7, 9 and 13): $_________ Total Living Expenses 15a: $_________ Differential (+/-): $_________ For Official Use Only When Filled In

ENLISTEE FINANCIAL STATEMENT

18. I certify that the information given in this statement is a true account of my financial obligations and that my dependents (line out as appropriate) DO/DO NOT require any special medical attention/treatment.

___________________________________________________ ___________________________________________

Signature of Applicant (Date) Signature of Spouse (Date)

___________________________________________________ ___________________________________________

AUTHENTICATING RECRUITER (Print Name) Signature of Recruiter (Date)

19. Command Representative Interview. I have determined member is handling present personal and financial affairs in a mature, competent, and responsible manner; can meet current and expected financial obligations with service pay; and I have counseled the member concerning potential problems that may be experienced at the onset of enlistment relating to financial matters and the assignment to possible dependent restricted tours.

_____________________________________ __________________________________ ___________________

Command Representative Signature Rank/Title of Position Interview Date

20. Interviewer’s Comments and Recommendation:

For Official Use Only When Filled In

NAVCRUIT 1130/13 (Rev. 10-06)