Transcription of OMB No. 0730-0014 DEPENDENCY STATEMENT - PARENT …
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OMB No. 0730-0014 DEPENDENCY STATEMENT - PARENT …
DEPENDENCY STATEMENT - PARENTPLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO YOUR LOCAL SERVING No. 0730-0014 OMB approval expires Nov 30, 2010 CONTROL NUMBERPRIVACY ACT STATEMENTAUTHORITY: 93-64; 37 , Chapter 7, Section 403; 9397 (SSN); and DoDFMR , Vol. 7a, Chapter PURPOSE(S): The information will be used to determine the relationship and DEPENDENCY of the claimed dependentsand determine the member's entitlement to authorized USE(S): In addition to those disclosures generally permitted under 5 552a(b) of the Privacy Act, these records orinformation contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 552a(b)(3) asfollows: The DoD "Blanket Routine Uses" published at the beginning of the DoD compilation of systems of records notices : Voluntary; however, failure to provide this information will result in a suspension of the dependent entitlement until themilitary member provides the required The member must complete Items 1 and 2, and sign and date the form.
notarized. If a representative completes the form for the parent(s), include in the Remarks section the name of the individual, the relationship, and the reason the form was not completed by parent(s). If the member is deceased, information furnished must reflect the 12 months prior to member's death. NOTES: Answer all questions. If any ...
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