DFAS Form 9124 "Affidavit of in Loco Parentis Relationship"

Form 9124 is a U.S. Department of Defense - Defense Finance and Accounting Service form also known as the "Affidavit Of In Loco Parentis Relationship". The latest edition of the form was released in May 1, 2011 and is available for digital filing.

Download a fillable PDF version of the Form 9124 down below or find it on U.S. Department of Defense - Defense Finance and Accounting Service Forms website.

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Download DFAS Form 9124 "Affidavit of in Loco Parentis Relationship"

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AFFIDAVIT OF IN LOCO PARENTIS RELATIONSHIP
INQUIRIES DIVISION CENTRALIZED PAY OPERATIONS U.S. ARMY FINANCE & ACCOUNTING CENTER INDIANAPOLIS, IN 46249
BLOCK A
BLOCK B
NAME OF ALLEGED PARENT
SERVICE MEMBER'S NAME
SERVICE MEMBER'S SOCIAL SECURITY NUMBER
THE PRIVACY ACT OF 1974
BY AUTHORITY OF PUBLIC 93 - 64, AND THE INFORMATION SOLICITED ON THIS FORM WILL BE USED TO DETERMINE ELIGIBILITY OF A PERSON
"STANDING IN PLACE OF A NATURAL/STEPPARENT" AS A BASIS FOR PAYMENT OF BASIC ALLOWANCE FOR QUARTERS (BAQ). ALTHOUGH
DISCLOSURE IS VOLUNTARY, BAQ CANNOT BE PAID UNTIL SUCH TIME AS ELIGIBILITY OF SECONDARY DEPENDENT IS ESTABLISHED.
NAME AS SHOWN IN BLOCKS A OR B ABOVE
SUBMITS THE FOLLOWING STATEMENT IN ANSWER TO THE QUESTIONS LISTED BELOW
IN SUPPORT OF MY CLAIM THAT AN IN LOCO PARENTIS RELATIONSHIP EXISTS BETWEEN
THE SERVICE MEMBER AND THE ALLEGED PARENT SHOWN ABOVE.
QUESTIONS
ANSWERS
PERIOD
ADDRESS
1. IN WHAT PLACES AND WHAT PERIODS OF TIME
FROM
STREET ADDRESS
DID THE SERVICE MEMBER ACTUALLY RESIDE
WITH THE ALLEGED PARENT AS A MEMBER OF HIS
(HER) HOUSEHOLD
TO
CITY, STATE
NAME OF MOTHER
MOTHER'S ADDRESS
2. GIVE NAMES AND ADDRESSES OF SERVICE
MEMBER'S NATURAL PARENTS
NAME OF FATHER
FATHER'S ADDRESS
DATE
PLACE
3. GIVE THE PLACE AND DATE OF BIRTH OF THE
SERVICEMEMBER
4. GIVE CIRCUMSTANCES UNDER WHICH THIS
SERVICE PERSON BECAME A MEMBER OF THE
ALLEGED PARENT'S HOUSEHOLD. (GIVE
COMPLETE DETAILS INCLUDING HOW CUSTODY
WAS OBTAINED FURNISHING COPY OF
AGREEMENT IF REDUCED TO WRITING)
5. DID THE ALLEGED PARENT PROVIDE A SERVICE
EDUCATION
YES
NO
RELIGIOUS GUIDANCE
YES
NO
MEMBER'S
6 ALLEGED PARENT PROVIDED FOR THE SERVICE
FROM
TO
FROM
TO
MEMBER'S SUPPORT:
NAME
RELATIONSHIP
7. OTHER FINANCIAL ASSISTANCE WAS RECEIVED
FROM:
ADDRESS
AMOUNT
SIGNATURE OF AFFIANT
NOTE: PENALTY FOR MAKING FALSE CLAIMS IS
PUNISHABLE BY FINE OR IMPRISONMENT OR BOTH.
NOTARY PUBLIC
SUBSCRIBED AND DULY SWORN TO BEFORE ME THIS
DAY OF
,
SIGNATURE OF NOTARY
OFFICIAL TITLE
OFFICIAL SEAL
COUNTY
STATE OR TERRITORY
MY COMMISSION EXPIRES
P
DF AS
Page 1 of 1
PREVIOUS EDITIONS ARE OBSOLETE
FORM 9124 MAY, 2011
ADOBE ACROBAT
RESET FORM
PRINT FORM
SUBMIT BY EMAIL
AFFIDAVIT OF IN LOCO PARENTIS RELATIONSHIP
INQUIRIES DIVISION CENTRALIZED PAY OPERATIONS U.S. ARMY FINANCE & ACCOUNTING CENTER INDIANAPOLIS, IN 46249
BLOCK A
BLOCK B
NAME OF ALLEGED PARENT
SERVICE MEMBER'S NAME
SERVICE MEMBER'S SOCIAL SECURITY NUMBER
THE PRIVACY ACT OF 1974
BY AUTHORITY OF PUBLIC 93 - 64, AND THE INFORMATION SOLICITED ON THIS FORM WILL BE USED TO DETERMINE ELIGIBILITY OF A PERSON
"STANDING IN PLACE OF A NATURAL/STEPPARENT" AS A BASIS FOR PAYMENT OF BASIC ALLOWANCE FOR QUARTERS (BAQ). ALTHOUGH
DISCLOSURE IS VOLUNTARY, BAQ CANNOT BE PAID UNTIL SUCH TIME AS ELIGIBILITY OF SECONDARY DEPENDENT IS ESTABLISHED.
NAME AS SHOWN IN BLOCKS A OR B ABOVE
SUBMITS THE FOLLOWING STATEMENT IN ANSWER TO THE QUESTIONS LISTED BELOW
IN SUPPORT OF MY CLAIM THAT AN IN LOCO PARENTIS RELATIONSHIP EXISTS BETWEEN
THE SERVICE MEMBER AND THE ALLEGED PARENT SHOWN ABOVE.
QUESTIONS
ANSWERS
PERIOD
ADDRESS
1. IN WHAT PLACES AND WHAT PERIODS OF TIME
FROM
STREET ADDRESS
DID THE SERVICE MEMBER ACTUALLY RESIDE
WITH THE ALLEGED PARENT AS A MEMBER OF HIS
(HER) HOUSEHOLD
TO
CITY, STATE
NAME OF MOTHER
MOTHER'S ADDRESS
2. GIVE NAMES AND ADDRESSES OF SERVICE
MEMBER'S NATURAL PARENTS
NAME OF FATHER
FATHER'S ADDRESS
DATE
PLACE
3. GIVE THE PLACE AND DATE OF BIRTH OF THE
SERVICEMEMBER
4. GIVE CIRCUMSTANCES UNDER WHICH THIS
SERVICE PERSON BECAME A MEMBER OF THE
ALLEGED PARENT'S HOUSEHOLD. (GIVE
COMPLETE DETAILS INCLUDING HOW CUSTODY
WAS OBTAINED FURNISHING COPY OF
AGREEMENT IF REDUCED TO WRITING)
5. DID THE ALLEGED PARENT PROVIDE A SERVICE
EDUCATION
YES
NO
RELIGIOUS GUIDANCE
YES
NO
MEMBER'S
6 ALLEGED PARENT PROVIDED FOR THE SERVICE
FROM
TO
FROM
TO
MEMBER'S SUPPORT:
NAME
RELATIONSHIP
7. OTHER FINANCIAL ASSISTANCE WAS RECEIVED
FROM:
ADDRESS
AMOUNT
SIGNATURE OF AFFIANT
NOTE: PENALTY FOR MAKING FALSE CLAIMS IS
PUNISHABLE BY FINE OR IMPRISONMENT OR BOTH.
NOTARY PUBLIC
SUBSCRIBED AND DULY SWORN TO BEFORE ME THIS
DAY OF
,
SIGNATURE OF NOTARY
OFFICIAL TITLE
OFFICIAL SEAL
COUNTY
STATE OR TERRITORY
MY COMMISSION EXPIRES
P
DF AS
Page 1 of 1
PREVIOUS EDITIONS ARE OBSOLETE
FORM 9124 MAY, 2011
ADOBE ACROBAT
RESET FORM
PRINT FORM
SUBMIT BY EMAIL
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