DEPENDENCY APPLICATION (1751 ... - marforres.marines.mil

1 DEPENDENCY APPLICATION (1751)NAVMC 10922 (REV. 4-01) (EF)(Supersedes all previous editions which are obsoleteand will not be used)INSTRUCTIONSWHERE ADDITIONAL SPACE ISNECESSARY TO COMPLETE ITEMS,DATE OF APPLICATION REASON FOR THIS APPLICATION (CHECK ONE)CHANGE IN DEPENDENTS(Check one)STARTCHANGE IN DEPENDENTSGAINSECTION OF MARINE (Last, first, middle) SSN GRADE TYPE OF SERVICEORGANIZATION AND STATION PREPARING THIS APPLICATION USMCUSMCRFUTURE ADDRESS AND ETA IF TRANSFER IS ANTICIPATED WITHIN 60 DAYS UNIT RUC ECCDATE OF CURRENT ENLISTMENT/APPOINTMENTOR DATE REPORTING FOR ACTIVE DUTY(WHICHEVER IS LATER) DATE OF LAST DISCHARGE OR DATE OF LASTRELEASE TO INACTIVE DUTY SECTION 2 DEPENDENT OF DEPENDENT(Include full given name)COMPLETE ADDRESS(Include Zip Code)

2 RELATIONSHIPDATE OFBIRTH(Day, Mo., Year)DATE ALLOWANCECLAIMED FROM (Ifpreviously approved,give date of approval)123456 SECTION 3 Furnish the following information concerning custodian of any dependent named NAME OF CUSTODIANRELATIONSHIP TODEPENDENTADDRESS AND ZIP CODEINFORMATION CONCERNING PRESENT MARRIAGE SECTION 4 MARITAL OF SERVICE MEMBER AND SPOUSE ANDINFORMATION REGARDING SUPPORT/PATERNITYDATEPLACE (County and State) FULL GIVEN NAME OF SPOUSEHAVE YOU BEEN PREVIOUSLYMARRIED?NOYESNO OFTIMESHAS PRESENT SPOUSE BEENPREVIOUSLY MARRIED?NOYESNO OFTIMESIF EITHER ANSWER ABOVE ISINFORMATION CONCERNING DISSOLUTION OF EACH FORMER MARRIAGE OF BOTH YOURSELF AND/OR SPOUSE (Continue on separate sheet if necessary)FORMERMARRIAGE OFNAME OF THE SPOUSE IN THE DISSOLVED MARRIAGEDATE OF DISSOLUTIONP lace of dissolution(County and State)REASON (Check one)DEATHANNULMENTDIVORCEIS THERE A COURT ORDER OR WRITTEN AGREEMENT IN EFFECT RELATIVE TO SUPPORT/MAINTENANCE/PATERNITY?

3 IF YES, STATE DATE AND PLACE (county and state) WHERE SUCH ORDER/AGREEMENT WAS ISSUED AND ATTACH A YOUR-SPOUSEORIGINALA dobe Designer I CERTIFY that all the above statements are true to the best of myknowledge and belief, and I consent to checkage against my pay for anyallowances paid on laws and regulations. I will immediately inform myCommanding Officer of any change in the number and/or status of mydependents, whether it be the gain of additional dependents, or the lossof 10922 (Rev. 4-01) (EF) Page 2 HAS NATURAL PARENT OTHER THAN CLAIMANT OF CHILD( REN) LISTED EVER BEEN A MEMBER OF ANYNOSECTION 5 NATURAL PARENT OF CHILD IN ARMED FORCESYESSECTION 6 SPOUSE IN ARMED FORCESHAS YOUR SPOUSE EVER BEEN A MEMBER OF ANY ARMED FORCE?

4 IF YES, COMPLETE THE BLOCKS OF SERVICEBRANCH OF SERVICEINCLUSIVE DATES OF ACTIVE SERVICEBAQREGULARRESERVEWITH DEPENDENTSWITHOUT DEPENDENTSBy signing this form, I hereby authorize release of any information hereonor obtained as a result of the processing/adjudication of this APPLICATION , tomy claimed dependents or custodians thereof, to the extent necessary forthe proper adjudication of benefits, entitlements and/or of my legalobligation to support my dependents. ORIGINALNAME OF MARINE (Last, first, middle) (Signature and Title of Attesting Officer )FOR USE BY UNIT DIARY CLERK:FOR USE BY COMMAND APPROVING AUTHORITY:SECTION 7 CERTIFICATIONNO.(Signature of Commanding Officer)(Typed Name and Grade of Commanding Officer)(Unit Designation)DATEDRUCAPPROVED ASCLAIMEDFORWARDED TO CMC(CODE MRP-1) FORAPPROVAL FORDEPENDENT NUMBERSAPPROVED FORDEPENDENTNUMBERS:SECTION 8 APPROVING AUTHORITYFOR USE BY CMC APPROVING AUTHORITY:APPROVED FOR CHILD BORNOUT OF WEDLOCK FOR DEERSELIGIBILITY PER CHECK ONECHILDRESIDES INMEMBER'SHOUSEHOLDCOURTORDER(Recertify annually)No Court OrderDocument Viewed(Signature of Marine)(Social Security Number)(Grade)Subscribed and sworn before me thisday of20 NAVMC 10922 ( ) (EF) Page 2 SECTION 8 APPROVING AUTHORITYD ocument ViewedNAVMC 10922 ( ) (EF) Page 2