Fill and Sign the What Does a Certificat Fo Trust Look Like Form

APPLICATION FOR BASIC ALLOWANCE FOR QUARTERS FOR MEMBERS WITH DEPENDENTS (Use only when determination of dependency must be made by USAFAC or AFAFC) PRIVACY ACT INFORMATION 1. AUTHORITY: Pub. L. 9364, E.O. 9397, 93d Congress. 2. PRINCIPAL PURPOSE(S): Adjudication of claims for Basic Allowance for Quarters (BAQ), for primary doubtful and secondary dependents. 3. ROUTINE USE(S): To secure documents (DD Form 137-3, Marriage Certificates, Birth Certificates, etc.) from the claimed dependent to determine the relationship and dependency. Documents are evaluated to determinem member’s entitlement to BAQ and input is made to the Master Military Pay File to authorize BAQ. The documents are retained or returned to the dependent. 4. DISCLOSURE IS VOLUNTARY: However, unless the required information is furnished, the allowance will not be paid. SSN NAME OF SERVICE MEMBER (Last, first, middle initial) STATION OR BASE 1. PAY GRADE DATE OF ENLISTMENT OR DATE OF ENTRY ON ACTIVE DUTY (Whichever is later) (YYMMDD) (YYMMDD) I HEREBY CLAIM BASIC ALLOWANCE FOR QUARTERS FOR THE DEPENDENTS LISTED BELOW EFFECTIVE (Date) 2. FROM THE DATE INDICATED ABOVE, MY DEPENDENTS ARE: NAME OF DEPENDENT (Last, first, middle initial) FAMILIAL RELATIONSHIP 1 COMPLETE CURRENT ADDRESS STREET ZIP CODE CITY STATE STREET ZIP CODE CITY STATE STREET ZIP CODE CITY DATE (YYMMDD) OF PRESENT MARRIAGE 3. STATE PLACE OF PRESENT MARRIAGE CITY IF ANY CHILD ABOVE HAS BEEN ADOPTED, SHOW DATE OF ADOPTION AND ADDRESS OF COURT ISSUING DECREE DATE (YYMMDD) ADDRESS OF COURT (City, State, and Zip Code) STATE IF ANY CHILD(REN) NAMED ABOVE AND NOT IN LEGAL CUSTODY OF YOU OR YOUR SPOUSE, SHOW THE FOLLOWING. NAME OF CHILD (Last, first, middle NAME (Last, first, middle initial) OF PERSON HAVING CUSTODY Amount of your monthly contribution for support of child initial) $ If support of child is required by court order Relationship of custodian to child COMPLETE ADDRESS OF PERSON HAVING CUSTODY or divorce decree, show amount required. STREET ZIP CODE CITY 4. DATE OF BIRTH 2 (YYMMDD) Specify amount per mo./yr. $ STATE DEPENDENCY INFORMATION (This section must be completed for all dependents other than lawful spouse and/or legitimate children under 21 years of age.) Monthly amount of my contribution NAME(S) OF DEPENDENT(S) (Last, first, middle initial) Dependent’s monthly income from other sources 3 $ Dependent’s monthly living expenses $ $ For unmarried child over 21 years of age, either physically incapacitated or mentally defective, attach a statement from a physician showing how long the child has been under his or her care and the cause and degree of incapacitation. If the child is in the custody of someone other than the member, a statement signed by the custodian showing amount of member’s monthly contribution, method by which contribution is made, and actual monthly living expense of the child is also required. 5. IF DIVORCED SHOW THE FOLLOWING: DIVORCE DECREE GRANTED BY NAME OF COURT STATE ADDRESS OF FORMER SPOUSE STREET TYPE OF DECREE Final DATE (YYMMDD) Interlocutory NAME OF PERSON FORMER SPOUSE REMARRIED (If applicable) (Last, first, middle initial) CITY STATE ZIP CODE Date decree is final (YYMMDD) 6. Have any of the above named dependents served as a member of the uniformed services or participated in full time training duty with pay after the date shown in item 1 above? 7. FIRST APPLICATION 8. IMPORTANT NOTE: Making a false statement or claim against the U.S. Government is punishable by court martial. PENALTY: The penalty for willfully making a false claim or a false statement in connection with claims: A maximum fine of $10,000 or maximum imprisonment of 5 years or both (18 U.S.C. 287-1001.) I will immediately notify the appropriate officer of any change in the dependency status of my dependents. The facts I have stated in connection with this request are correct. CURRENT DATE (YYMMDD) Signature of service member I have received the attached supporting documentary evidence presented to establish dependency of the above named dependents and have satisfied myself that the statements by the member are true and correct. CURRENT DATE (YYMMDD) Signature of reviewing officer YES NO YES NO DATE LAST APPLICATION FILED (YYMMDD) : TO BE COMPLETED BY USAFAC/AFAFC Dependency of above named dependent(s) has been established effective (YYMMDD). 1/ Indicate if step or adopted child DD Form 137, FEB 84 (EG) 2/ Children only It has been determined that the above named individual(s) is/are not dependent on the service member for the following reasons: 3/ Include interest, dividend or rental income and contributions from others toward household or living expenses. EDITION OF JUNE 80 WILL BE USED Designed using Perform Pro, WHS/DIOR, Jan 97