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.
NAME OF SERVICE MEMBER (Last, first, middle initial)
STATION OR BASE
DATE OF ENLISTMENT OR DATE OF ENTRY ON ACTIVE DUTY
(Whichever is later) (YYMMDD)
I HEREBY CLAIM BASIC ALLOWANCE FOR QUARTERS FOR THE DEPENDENTS LISTED BELOW EFFECTIVE
FROM THE DATE INDICATED ABOVE, MY DEPENDENTS ARE:
DATE OF BIRTH 2
NAME OF DEPENDENT (Last, first, middle initial)
COMPLETE CURRENT ADDRESS
PLACE OF PRESENT MARRIAGE
IF ANY CHILD ABOVE HAS BEEN ADOPTED, SHOW DATE OF
ADOPTION AND ADDRESS OF COURT ISSUING DECREE
ADDRESS OF COURT (City, State, and Zip Code)
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
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.
Specify amount per mo./yr.
(This section must be completed for all dependents other than lawful spouse and/or legitimate children under 21 years of age.)
Monthly amount of
NAME(S) OF DEPENDENT(S) (Last, first, middle initial)
income from other
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.
IF DIVORCED SHOW THE FOLLOWING:
ADDRESS OF FORMER SPOUSE
TYPE OF DECREE
DIVORCE DECREE GRANTED BY
NAME OF COURT
NAME OF PERSON FORMER SPOUSE REMARRIED (If applicable)
Date decree is final
(Last, first, middle initial)
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?
DATE LAST APPLICATION FILED (YYMMDD) :
I will immediately notify the appropriate officer of any change in the
IMPORTANT NOTE: Making a false statement or claim against the U.S.
dependency status of my dependents. The facts I have stated in connection
Government is punishable by court martial.
with this request are correct.
PENALTY: The penalty for willfully making a false claim or a false
Signature of service member
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 have received the attached supporting documentary evidence presented to establish dependency
Signature of reviewing officer
of the above named dependents and have satisfied myself that the statements by the member are
true and correct.
TO BE COMPLETED BY USAFAC/AFAFC
It has been determined that the above named individual(s) is/are
Dependency of above named dependent(s) has been established effective
not dependent on the service member for the following reasons:
1/ Indicate if step or adopted child
2/ Children only
3/ Include interest, dividend or rental income and contributions from others
toward household or living expenses.
DD Form 137, FEB 84 (EG)
EDITION OF JUNE 80 WILL BE USED
Designed using Perform Pro, WHS/DIOR, Jan 97