DA Form 5328 Bona Fide Dependent Declaration (Civilian)

DA Form 5328 - also known as the "Bona Fide Dependent Declaration (civilian)" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 5328 - was last revised on February 1, 2009. Download an up-to-date fillable PDF version of the DA 5328 below or request a copy through the chain of command.

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BONA FIDE DEPENDENT DECLARATION (Civilian)
For use of this form, see AR 638-2; the proponent agency is DCS, G-1.
CERTIFICATE
(Date)
The following information has been extracted from the Official Personnel Record on the employee named below:
(Name of Employee)
(Pay Plan & Grade)
(Name and Address of Unit)
(Date of Hire)
(Place of Hire)
(Date DD Form 1617 Signed)
(Place of Actual Residence at Time of Appointment)
(Name of Deceased Dependent)
(Date of Death (YYMMDD))
(Relationship of Employee)
DEFINITIONS OF DEPENDENTS (Check appropriate item)
1. A dependent of a DOD civilian employee is considered to be any of the following named members of the employee's household at the time
he/she reports for duty at his/her new permanent duty station or performs authorized or approved overseas tour renewal agreement travel or
separation travel:
a. a spouse.
b. children of the employee or employee's spouse who are unmarried and under 21 years of age or who, regardless of age, are
physically or mentally incapable of self-support. (The term "children" will include natural offspring; stepchildren; adopted children; grandchildren;
legal minor wards, or other dependent children who are under legal guardianship of the employee or employee's spouse, and a child born after
the employee's effective date of transfer when the travel of the employee's expectant spouse to the new permanent duty station is prevented at
the time of transfer because of advanced stage of pregnancy, or other reasons acceptable to the DOD component concerned, e.g., awaiting
completion of the school year by other children);
c. dependent parents (including step and legally adoptive parents) of the employee or employee's spouse; and
d. dependent brothers and sisters (including step and legally adoptive brothers and sisters) of the employee or employee's
spouse who are unmarried and under 21 years of age or who, regardless of age, are physically or mentally incapable of self-support.
2. Generally, the individuals named in items 1c and 1d will be considered dependents of the employee if they receive at least 51% of their
support from the employee or employee's spouse; however, this percentage of support criteria shall not be the decisive factor in all cases.
These individuals may also be considered dependents for the purpose of this definition if they are members of the employee's household
and, in addition to their own income, receive support (less than 51%) from the employee or employee's spouse without which they would
be unable to maintain a reasonable standard of living.
TYPED NAME OF CIVILIAN PERSONNEL OFFICER
GRADE
ORGANIZATION AND ADDRESS
SIGNATURE OF CIVILIAN PERSONNEL OFFICER
APD LC v1.00ES
DA FORM 5328, FEB 2009
PREVIOUS EDITION IS OBSOLETE
BONA FIDE DEPENDENT DECLARATION (Civilian)
For use of this form, see AR 638-2; the proponent agency is DCS, G-1.
CERTIFICATE
(Date)
The following information has been extracted from the Official Personnel Record on the employee named below:
(Name of Employee)
(Pay Plan & Grade)
(Name and Address of Unit)
(Date of Hire)
(Place of Hire)
(Date DD Form 1617 Signed)
(Place of Actual Residence at Time of Appointment)
(Name of Deceased Dependent)
(Date of Death (YYMMDD))
(Relationship of Employee)
DEFINITIONS OF DEPENDENTS (Check appropriate item)
1. A dependent of a DOD civilian employee is considered to be any of the following named members of the employee's household at the time
he/she reports for duty at his/her new permanent duty station or performs authorized or approved overseas tour renewal agreement travel or
separation travel:
a. a spouse.
b. children of the employee or employee's spouse who are unmarried and under 21 years of age or who, regardless of age, are
physically or mentally incapable of self-support. (The term "children" will include natural offspring; stepchildren; adopted children; grandchildren;
legal minor wards, or other dependent children who are under legal guardianship of the employee or employee's spouse, and a child born after
the employee's effective date of transfer when the travel of the employee's expectant spouse to the new permanent duty station is prevented at
the time of transfer because of advanced stage of pregnancy, or other reasons acceptable to the DOD component concerned, e.g., awaiting
completion of the school year by other children);
c. dependent parents (including step and legally adoptive parents) of the employee or employee's spouse; and
d. dependent brothers and sisters (including step and legally adoptive brothers and sisters) of the employee or employee's
spouse who are unmarried and under 21 years of age or who, regardless of age, are physically or mentally incapable of self-support.
2. Generally, the individuals named in items 1c and 1d will be considered dependents of the employee if they receive at least 51% of their
support from the employee or employee's spouse; however, this percentage of support criteria shall not be the decisive factor in all cases.
These individuals may also be considered dependents for the purpose of this definition if they are members of the employee's household
and, in addition to their own income, receive support (less than 51%) from the employee or employee's spouse without which they would
be unable to maintain a reasonable standard of living.
TYPED NAME OF CIVILIAN PERSONNEL OFFICER
GRADE
ORGANIZATION AND ADDRESS
SIGNATURE OF CIVILIAN PERSONNEL OFFICER
APD LC v1.00ES
DA FORM 5328, FEB 2009
PREVIOUS EDITION IS OBSOLETE

Download DA Form 5328 Bona Fide Dependent Declaration (Civilian)

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