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.

DEPENDENCY STATEMENT - PARENT ... EXPENSE (2) TOTAL EXPENSE FOR PAST 12 MONTHS ITEM (1) PRESENT MONTHLY EXPENSE (2) TOTAL EXPENSE FOR PAST 12 MONTHS a. CLOTHING b. LAUNDRY AND DRY ... If any income received during the past 12 months was a lump-sum (one-time) payment, be sure to state this. Verification documents are

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