DD Form 137-5 "Dependency Statement - Incapacitated Child Over Age 21"

What Is DD Form 137-5?

This is a form that was released by the U.S. Department of Defense (DoD) on March 1, 2018. The form, often mistakenly referred to as the DA Form 137-5, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DoD.

Form Details:

  • A 5-page document available for download in PDF;
  • The latest version available from the Executive Services Directorate;
  • Additional instructions and information can be found on page 1 of the document;
  • Editable, printable, and free to use;
  • Fill out the form in our online filing application.

Download an up-to-date fillable DD Form 137-5 down below in PDF format or browse hundreds of other DoD Forms compiled in our online library.

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DD Form 137-5 Instructions

The DD Form 137-5 contains fifteen sections overall and must be completed entirely: if any questions are not applicable to a particular situation, write NOT APPLICABLE (or N/A) in that block. No fields should be left blank - incomplete forms will take longer to process.

  1. Section 1 describes the requested entitlements and information about previous applications for benefits.
  2. Section 2, Member Information, contains 9 Boxes in total. The information required within these boxes includes the name, DoD ID number, rank, and status of the applicant, their home and military addresses, phone numbers, email address and marital status.
  3. Section 3 is only for the information about the child being claimed. The applicant must provide the name, DoD ID and date of birth of the child, their relationship to the applicant, their complete address and marital status.
  4. Section 4 is for providing information about the other parent. Boxes 4c and 4d must be filed for military parents in any branch of service including Reserve and National Guard.
  5. Section 5 is self-explanatory - it specifies the child's current living conditions and the amount of time living at the listed address.
  6. Section 6 is filed only if the child is currently in a hospital or institution. Section 8 must be left blank if the child resides at the facility full time. If the child is staying at the facility part-time, both Sections 6 and 8 must be filled out. The Army requires an official letter from the institution or facility with a run-down of all costs and expenses. All information must be correct and provided in full - forms are regularly rejected because of incorrect or incomplete information in this section.
  7. Section 7 is self-explanatory and is meant for listing the people sharing a household with the child. The list should include everyone including the applicant filing the DD 137-5. This section cannot be left blank even if the service member and their child are the only people living in the household.
  8. Section 8 is for providing a detailed list of household expenses for all people living in the household.
  9. Section 9 is for describing the child's personal expenses regardless of who pays for them.
  10. Section 10 has lines for specifying the gross income made by or on behalf of the child, whether taxable or not. The personal income of the service member should not be included.
  11. Section 11 is filed in cases if the claimed child had been employed within the last 12 months.
  12. Section 12, Child's School Attendance is for describing the child's educational career. Include all schooling even if it is a vocational or a degree-seeking program.
  13. Section 13 is for listing all contributions made towards caring for the child over the last 12 months. Proof of support is required for BAH.
  14. Section 14 is for additional remarks and Section 15 is for the signatures and certification. All signature and dates must be notarized.

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CUI (when filled in)
OMB No. 0730-0014
DEPENDENCY STATEMENT - INCAPACITATED CHILD OVER AGE 21
OMB approval expires
June 30, 2024
The public reporting burden for this collection of information, 0730-0014, is estimated to average 30-60 minutes 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 the burden estimate or burden
reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.
RETURN COMPLETED FORM TO YOUR LOCAL SERVING PERSONNEL/PAYROLL OFFICE.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 37 U.S.C., Pay and Allowances of the Uniformed Services; DoD Directive 5154.29, DoD Pay and
Allowances Policy and Procedures; DoD 7000.14-R, DoD Financial Management Manual, Volume 7A, Military Pay Policy and Procedures – Active Duty and
Reserve Pay; and Joint Travel Regulations (JTR) current edition.
PURPOSE(S): The information will be used to determine the relationship and dependency of the claimed dependents and determine the member's entitlement of
authorized benefits.
ROUTINE USE(S): To the Treasury Department to provide information on check issues and electronic funds transfers. To Federal, state, and local governmental
agencies in response to an official request for information with respect to law enforcement, investigatory procedures, criminal prosecution, civil court action and
regulatory order. Additional routine uses can be found within the applicable system of records notices, T7344, Defense Joint Military Pay System-Reserve
Component; T7340, Defense Joint Military Pay System-Active Component; and M01040-3, Marine Corps Manpower Management Information System Records,
located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/
DISCLOSURE: Voluntary: however, failure to provide this information will result in a suspension of the dependent entitlements until the member can provide the
required certificate.
INSTRUCTIONS
The member must complete the form in its entirety, sign and date the form, and have it notarized. If the child resides alone or with someone other than the
member, the member completes Items 1, 2, and 16, signs and dates the form, and the child or child's representative completes Items 3 through 15, signs and
dates the form, and has it notarized. If the member is deceased, the child or child's representative completes the form in its entirety, signs and dates the form,
and has it notarized. Information furnished must reflect the 12 months prior to member's death. Verification of income is required.
NOTES: 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
BAH
USIP CARD
YES
(If No, give date of last application)
APPROVED
TRAVEL ALLOWANCE
NO
(YYYYMMDD)
DISAPPROVED
2. MEMBER INFORMATION
a. NAME (Last, First, Middle Initial)
b. DoD ID NUMBER
c. RANK
d. STATUS (X and complete as applicable)
ACTIVE DUTY
NATIONAL GUARD
ARMY
NAVY
DECEASED
(Date of death) (YYYMMDD)
RETIRED
RESERVE
MARINE CORPS
AIR FORCE
OTHER
(Specify)
e. COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
f. COMPLETE MILITARY ADDRESS (Include assignment: squadron and base)
g. TELEPHONE NUMBERS (Include DSN or Area Code)
i. MARITAL STATUS (X one)
h. E-MAIL ADDRESS
(1) WORK
(2) HOME
SINGLE
SEPARATED
WIDOWED
MARRIED
DIVORCED
3. MEMBER'S CHILD
a. NAME (Last, First, Middle Initial)
b. DOD ID NUMBER
c. DATE OF BIRTH (YYYYMMDD)
d. RELATIONSHIP TO MEMBER (X one)
LEGITIMATE CHILD
CHILD BORN OUT OF WEDLOCK
ADOPTED CHILD
STEPCHILD
e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
f. 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
DD FORM 137-5, MAR 2018
Controlled by: DFAS
Page 1 of 5
CUI (when filled in)
Category: PRVCY
PREVIOUS EDITION IS OBSOLETE.
Distribution/DISTRO: FEDCON
POC: (888) 332-7411
CUI (when filled in)
OMB No. 0730-0014
DEPENDENCY STATEMENT - INCAPACITATED CHILD OVER AGE 21
OMB approval expires
June 30, 2024
The public reporting burden for this collection of information, 0730-0014, is estimated to average 30-60 minutes 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 the burden estimate or burden
reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.
RETURN COMPLETED FORM TO YOUR LOCAL SERVING PERSONNEL/PAYROLL OFFICE.
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 37 U.S.C., Pay and Allowances of the Uniformed Services; DoD Directive 5154.29, DoD Pay and
Allowances Policy and Procedures; DoD 7000.14-R, DoD Financial Management Manual, Volume 7A, Military Pay Policy and Procedures – Active Duty and
Reserve Pay; and Joint Travel Regulations (JTR) current edition.
PURPOSE(S): The information will be used to determine the relationship and dependency of the claimed dependents and determine the member's entitlement of
authorized benefits.
ROUTINE USE(S): To the Treasury Department to provide information on check issues and electronic funds transfers. To Federal, state, and local governmental
agencies in response to an official request for information with respect to law enforcement, investigatory procedures, criminal prosecution, civil court action and
regulatory order. Additional routine uses can be found within the applicable system of records notices, T7344, Defense Joint Military Pay System-Reserve
Component; T7340, Defense Joint Military Pay System-Active Component; and M01040-3, Marine Corps Manpower Management Information System Records,
located at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Notices/
DISCLOSURE: Voluntary: however, failure to provide this information will result in a suspension of the dependent entitlements until the member can provide the
required certificate.
INSTRUCTIONS
The member must complete the form in its entirety, sign and date the form, and have it notarized. If the child resides alone or with someone other than the
member, the member completes Items 1, 2, and 16, signs and dates the form, and the child or child's representative completes Items 3 through 15, signs and
dates the form, and has it notarized. If the member is deceased, the child or child's representative completes the form in its entirety, signs and dates the form,
and has it notarized. Information furnished must reflect the 12 months prior to member's death. Verification of income is required.
NOTES: 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
BAH
USIP CARD
YES
(If No, give date of last application)
APPROVED
TRAVEL ALLOWANCE
NO
(YYYYMMDD)
DISAPPROVED
2. MEMBER INFORMATION
a. NAME (Last, First, Middle Initial)
b. DoD ID NUMBER
c. RANK
d. STATUS (X and complete as applicable)
ACTIVE DUTY
NATIONAL GUARD
ARMY
NAVY
DECEASED
(Date of death) (YYYMMDD)
RETIRED
RESERVE
MARINE CORPS
AIR FORCE
OTHER
(Specify)
e. COMPLETE RESIDENCE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
f. COMPLETE MILITARY ADDRESS (Include assignment: squadron and base)
g. TELEPHONE NUMBERS (Include DSN or Area Code)
i. MARITAL STATUS (X one)
h. E-MAIL ADDRESS
(1) WORK
(2) HOME
SINGLE
SEPARATED
WIDOWED
MARRIED
DIVORCED
3. MEMBER'S CHILD
a. NAME (Last, First, Middle Initial)
b. DOD ID NUMBER
c. DATE OF BIRTH (YYYYMMDD)
d. RELATIONSHIP TO MEMBER (X one)
LEGITIMATE CHILD
CHILD BORN OUT OF WEDLOCK
ADOPTED CHILD
STEPCHILD
e. COMPLETE ADDRESS (Street, Apartment Number, City, State, ZIP Code)
f. 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
DD FORM 137-5, MAR 2018
Controlled by: DFAS
Page 1 of 5
CUI (when filled in)
Category: PRVCY
PREVIOUS EDITION IS OBSOLETE.
Distribution/DISTRO: FEDCON
POC: (888) 332-7411
CUI (when filled in)
4. CHILD'S OTHER PARENT(S)
a.
b.
(1) NAME (Last, First, Middle Initial)
(1) NAME (Last, First, Middle Initial)
(2) RELATIONSHIP TO CHILD
(2) RELATIONSHIP TO CHILD
(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)
YES
NO
(If Yes, show rank, name, SSN, and military address.)
d. DOES OTHER PARENT CLAIM CHILD FOR BASIC ALLOWANCE FOR HOUSING (BAH), TRAVEL ALLOWANCE, OR USIP CARD (X one)
YES
NO
(If Yes, explain.)
5. CHILD'S RESIDENCE
a. TYPE OF RESIDENCE (X and complete as applicable)
HOME OR APARTMENT OF OTHER PARENT
HOME OR APARTMENT OF FRIEND OR RELATIVE (State relationship)
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)
d. DATE CHILD STARTED LIVING AT CURRENT ADDRESS (YYYYMMDD)
c. IS RESIDENCE SUBSIDIZED HOUSING?
YES
NO
6. IF CHILD IS IN HOSPITAL OR INSTITUTION
If child is in a hospital or institution, all of the following information must be furnished. Obtain this information from the hospital or institution.
a. DATE CHILD ENTERED HOSPITAL/INSTITUTION (YYYYMMDD)
b. ANTICIPATED DATE OF DISCHARGE (If known) (YYYYMMDD)
NO
c. WILL CHILD RETURN TO MEMBER'S HOME AFTER DISCHARGE? (If "NO," explain where child will reside)
YES
d. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION
(1)
(2)
(1)
(2)
ITEM
PRESENT MONTHLY
TOTAL EXPENSE FOR
ITEM
PRESENT MONTHLY
TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS
EXPENSE
PAST 12 MONTHS
(1) ROOM
(8) EDUCATION
(2) FOOD
(9) TRANSPORTATION
(10) PERSONAL INSURANCE
(3) REHABILITATION CLASSES
(Specify)
OR SERVICES
(4) SPECIALIZED EQUIPMENT
(11) OTHER (Specify)
(5) MEDICAL CARE
(6) CLOTHING
(7) LAUNDRY/DRY CLEANING
DD FORM 137-5, MAR 2018
Page 2 of 5
CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.
CUI (when filled in)
6. IF CHILD IS IN HOSPITAL OR INSTITUTION (Continued)
e. CHILD'S EXPENSES IN HOSPITAL OR INSTITUTION ARE PAID BY:
(1)
(2)
(1)
(2)
SOURCE
PRESENT MONTHLY
TOTAL EXPENSE FOR
SOURCE
PRESENT MONTHLY
TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS
EXPENSE
PAST 12 MONTHS
(1)
(a) CIVILIAN MEDICAL
(3) STATE OR LOCAL AGENCY
U
TREATMENT FACILITY
(Give name and address
S
(CHAMPUS)
in Remarks section)
I
P
C
(b) MILITARY MEDICAL
(4) MEMBER
A
TREATMENT FACILITY
R
D
(2) PRIVATE INSURANCE
(5) OTHER (Explain and give
(Give name and address
name and address in
in Remarks section)
Remarks section)
7. PERSONS LIVING IN HOUSEHOLD WITH CHILD
When child resides in a hospital or institution and Item 6 is completed, do not complete this item. 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.
d. MARRIED (X)
e. EMPLOYED
b. RELATIONSHIP
a. NAME (Last, First, Middle Initial)
c. AGE
TO CHILD
YES
NO
HOURS PER WEEK
NO (X)
8. HOUSEHOLD EXPENSES
When child resides in a hospital or institution and Item 6 is completed, do not complete this item. 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.
(1)
(2)
(1)
(2)
ITEM
PRESENT MONTHLY
TOTAL EXPENSE FOR
ITEM
PRESENT MONTHLY
TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS
EXPENSE
PAST 12 MONTHS
a. (X one)
d. FURNITURE AND
RENT
FRV
APPLIANCES
MORTGAGE (Specify
amount of tax and
insurance if applicable)
TAX
e. REPAIRS ON HOME
INSURANCE
b. FOOD
f. OTHER (Itemize in Remarks
c. UTILITIES (Heat, power,
section)
water, and telephone)
9. CHILD'S PERSONAL EXPENSES
When child resides in a hospital or institution and Item 6 is completed, do not complete this item. List all of the child's personal expenses regardless of who is paying for
them.
(1)
(2)
(1)
(2)
ITEM
PRESENT MONTHLY
TOTAL EXPENSE FOR
ITEM
PRESENT MONTHLY
TOTAL EXPENSE FOR
EXPENSE
PAST 12 MONTHS
EXPENSE
PAST 12 MONTHS
a. CLOTHING
g. PRIVATE AUTO PAYMENTS
(If auto is registered in
b. LAUNDRY AND DRY
child's name)
CLEANING
h. MONTHLY TRANSPORTA-
c. MEDICAL (Do not include
TION PAYMENTS (Specify
expenses paid by insurance,
type)
welfare, or Medicare)
d. VALUE OF USIP CARD
(Verification of amount is
required)
i. SCHOOL EXPENSES
e. PERSONAL INSURANCE
(Specify)
j. OTHER (Specify)
f. PERSONAL TAXES (Specify)
DD FORM 137-5, MAR 2018
Page 3 of 5
CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.
CUI (when filled in)
10. 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)
(2)
(1)
(2)
PRESENT
TOTAL INCOME
PRESENT
TOTAL INCOME
SOURCE
SOURCE
MONTHLY
FOR PAST 12
MONTHLY
FOR PAST 12
INCOME
MONTHS
INCOME
MONTHS
g. SOCIAL SECURITY PAYMENTS,
a. WAGES, SALARIES, TIPS, OR
DISABILITY OR REGULAR
OTHER CASH GRATUITIES
(Specify)
b. INTEREST ON INVESTMENTS,
BONDS, SAVINGS, TRUST
h. SUPPLEMENTAL
FUNDS, ETC.
SECURITY INCOME (SSI)
c. INSURANCE OR PUBLIC/
i. VETERANS ADMINISTRATION
GOVERNMENT PENSION
PAYMENTS (Specify type)
PAYMENTS,UNEMPLOYMENT
OR DISABILITY COMPENSATION
(Specify type)
j. STATE OR LOCAL WELFARE AID,
INCLUDING AID TO DEPENDENT
d. CONTRIBUTIONS FROM
CHILDREN (Include agency and
PERSONS OTHER THAN
address in Remarks section)
MEMBER
e. SCHOLARSHIPS OR
k. OTHER (Specify)
EDUCATIONAL GRANTS
f. TAX REFUNDS (Specify)
11. CHILD'S EMPLOYMENT (Show additional periods of work in the Remarks section.)
HAS CHILD BEEN EMPLOYED DURING THE PAST 12 MONTHS?
YES
NO (If Yes, furnish the following:)
(2) DATE EMPLOYMENT
(3) DATE EMPLOYMENT
(4) MONTHLY SALARY
(1) NAME OF EMPLOYER
STARTED (YYYYMMDD)
ENDED (YYYYMMDD)
(Gross)
a.
(5) TYPE OF WORK PERFORMED
(6) REASON EMPLOYMENT ENDED
(2) DATE EMPLOYMENT
(3) DATE EMPLOYMENT
(4) MONTHLY SALARY
(1) NAME OF EMPLOYER
STARTED (YYYYMMDD)
ENDED (YYYYMMDD)
(Gross)
b.
(5) TYPE OF WORK PERFORMED
(6) REASON EMPLOYMENT ENDED
(2) DATE EMPLOYMENT
(3) DATE EMPLOYMENT
(4) MONTHLY SALARY
(1) NAME OF EMPLOYER
STARTED (YYYYMMDD)
ENDED (YYYYMMDD)
(Gross)
c.
(5) TYPE OF WORK PERFORMED
(6) REASON EMPLOYMENT ENDED
d. IS OR WAS CHILD'S JOB CONSIDERED AS BEING A "SHELTERED WORKSHOP" - THAT IS, OPEN ONLY TO DISABLED OR HANDICAPPED PEOPLE?
YES
NO (If Yes, and child is currently working, attach a statement from the employer verifying this information.)
12. CHILD'S SCHOOL ATTENDANCE
HAS CHILD ATTENDED COLLEGE SINCE AGE 21?
YES
NO
(If Yes, furnish the following:)
(1) NAME AND ADDRESS OF SCHOOL
(2) (X as applicable)
VOCATIONAL
FOR RECEIVING DEGREE
a.
(4) (X)
(3) DATES ATTENDED
(5) CHILD'S MAJOR
FULL-TIME
PART-TIME
(1) NAME AND ADDRESS OF SCHOOL
(2) (X as applicable)
VOCATIONAL
FOR RECEIVING DEGREE
b.
(4) (X)
(3) DATES ATTENDED
(5) CHILD'S MAJOR
FULL-TIME
PART-TIME
DD FORM 137-5, MAR 2018
Page 4 of 5
CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.
CUI (when filled in)
13. MEMBER'S CONTRIBUTION
a. SHOW THE TOTAL AMOUNT THE MEMBER HAS CONTRIBUTED TO THE CHILD'S SUPPORT FOR EACH OF THE PAST 12 MONTHS.
(1) MONTH AND YEAR
(2) AMOUNT
(1) MONTH AND YEAR
(2) AMOUNT
(1) MONTH AND YEAR
(2) AMOUNT
ALLOTMENT
PERSONAL CHECK
MONEY ORDER
b. MEMBER PROVIDES SUPPORT BY (X one)
OTHER
(Explain)
11. REMARKS (Use back if necessary)
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. CUSTODIAN
I/we
(print name(s)) will immediately notify
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 PHYSICAL CUSTODY OF THE CHILD (Can be member
(2) RELATIONSHIP TO CHILD
(3) DATE SIGNED
or other than member)
(YYYYMMDD)
b. NOTARY PUBLIC
Subscribed and duly sworn (or affirmed) to before me according to law by the above named affiant(s).
day of
,
, at city (or town) of
, county of
This
,
and state (or territory) of
.
(Notary)
(Official Seal)
(Official Title)
c. MEMBER
(1) SIGNATURE
(2) DATE SIGNED (YYYYMMDD)
DD FORM 137-5, MAR 2018
Page 5 of 5
CUI (when filled in)
PREVIOUS EDITION IS OBSOLETE.
Page of 5