DD Form 137-4 Dependency Statement - Child Born Out Of Wedlock Under A

DEPENDENCY STATEMENT CHILD BORN OUT OF WEDLOCK
UNDER AGE 21

CONTROL NUMBER

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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark
Center Drive, Alexandria, VA 22350-3100 (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), as amended; and Joint Forces Travel Regulation (JFTR) Chapter 10.
PRINCIPAL PURPOSE(S): The information will be used to determine the relationship and dependency of the claimed dependents and determine the
member’s entitlement to authorized benefits.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b), as amended, 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 http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply.
Applicable SORNs: DJMS-AC/RC, DRAS: http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6277/t7340.aspx
http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6281/t7344.aspx
http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/6282/t7347b.aspx
USMC MCTFS: http://dpclo.defense.gov/Privacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/6774/m01040-3.aspx
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
MALE MEMBER WITH CHILD BORN OUT OF WEDLOCK WHOSE PATERNITY HAS NOT BEEN JUDICIALLY DETERMINED AND WHO DOES
NOT RESIDE IN MEMBER'S HOUSEHOLD. Member must complete Items 1 and 2, and sign and date the form. Child's custodian or representative
must complete Items 3 through 13, sign and date the form, and have it notarized. CHILD MUST BE MORE THAN 50% DEPENDENT ON MEMBER.
If member is deceased, representative of the child must complete this form in its entirety and have the form notarized. Items 5 through 11 must reflect
the 12 months prior to the member's death. Report income in GROSS amounts, and attach verification documentation.
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

b. FIRST APPLICATION?

c. LAST APPLICATION WAS

USIP CARD

YES

(If No, give date of last application)

APPROVED

OTHER (Specify)

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

e. 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

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

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

c. IS OTHER BIOLOGICAL PARENT IN ANY BRANCH OF SERVICE, INCLUDING RESERVE OR NATIONAL GUARD (X one)
(If Yes, show rank, name, SSN, and military address.)

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PREVIOUS EDITION IS OBSOLETE.

YES

NO

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Adobe Professional X

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

YES

NO

e. WAS CHILD'S MOTHER MARRIED FOR ANY PART OF THE 10-MONTH PERIOD PRECEDING THE CHILD'S BIRTH? (X one)
(If Yes, give date of marriage) (YYYYMMDD)

YES

NO

If the mother was married but is now separated, divorced, or widowed, furnish a copy of separation agreement, interlocutory decree, final divorce
decree, or death certificate of spouse.
f. HAS PATERNITY OF CHILD BEEN JUDICIALLY DIRECTED?
(If Yes, ID card can be issued.)
YES

NO

g. HAS MEMBER BEEN JUDICIALLY DIRECTED TO SUPPORT THE CHILD?
(If Yes, furnish a copy of all documents.)
YES

NO

D R A F T

5. CHILD'S RESIDENCE

a. TYPE OF RESIDENCE (X and complete as applicable)

HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)

HOME OR APARTMENT OF OTHER PARENT
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

e. DATE CHILD STARTED LIVING WITH PERSON WHO
CURRENTLY HAS PHYSICAL CUSTODY (YYYYMMDD)

NO

6. PERSONS LIVING IN HOUSEHOLD WITH CHILD
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

NO

e. EMPLOYED
HOURS PER WEEK

NO (X)

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 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

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

ITEM

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

d. FURNITURE AND
APPLIANCES
e. REPAIRS ON HOME
f. OTHER (Specify)

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

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8. CHILD'S PERSONAL EXPENSES
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

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

ITEM

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

a. CLOTHING
b. LAUNDRY AND DRY
CLEANING

h. MONTHLY TRANSPORTATION PAYMENTS (Specify
type)

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)

D R A F T

9. 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.
(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)

d. CONTRIBUTIONS FROM
PERSONS OTHER THAN
MEMBER

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

e. SCHOLARSHIPS OR
EDUCATIONAL GRANTS

k. OTHER (Specify)

f. TAX REFUNDS (Specify)

10. CHILD'S EMPLOYMENT
a. HAS CHILD BEEN EMPLOYED DURING THE PAST 12 MONTHS?

YES

NO (If Yes, furnish the following:)

b. NAME OF EMPLOYER
c. DATE EMPLOYMENT STARTED d. DATE EMPLOYMENT ENDED
(YYYYMMDD)
(YYYYMMDD)

e. MONTHLY SALARY (Gross)

f. TYPE OF WORK PERFORMED

g. REASON EMPLOYMENT ENDED

11. MEMBER'S CONTRIBUTION
a. SHOW THE TOTAL AMOUNT THE MEMBER HAS CONTRIBUTED TO THE CHILD'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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12. 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.)
13. 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 (OTHER THAN MEMBER) WHO HAS PHYSICAL
CUSTODY OF THE CHILD

(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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