Application For Basic Allowance For Quarters For Members With Dependents

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)

PAY GRADE

STATION OR BASE

DATE OF ENLISTMENT OR DATE OF ENTRY ON ACTIVE DUTY

(Whichever is later) (YYMMDD)

(YYMMDD)

1.

I HEREBY CLAIM BASIC ALLOWANCE FOR QUARTERS FOR THE DEPENDENTS LISTED BELOW EFFECTIVE

(Date)

2.

FROM THE DATE INDICATED ABOVE, MY DEPENDENTS ARE:

FAMILIAL

DATE OF BIRTH 2

NAME OF DEPENDENT (Last, first, middle initial)

COMPLETE CURRENT ADDRESS

RELATIONSHIP 1

(YYMMDD)

STREET

ZIP CODE

CITY

STATE

STREET

ZIP CODE

CITY

STATE

STREET

ZIP CODE

CITY

STATE

DATE (YYMMDD)

PLACE OF PRESENT MARRIAGE

IF ANY CHILD ABOVE HAS BEEN ADOPTED, SHOW DATE OF

ADOPTION AND ADDRESS OF COURT ISSUING DECREE

OF PRESENT

CITY

STATE

DATE (YYMMDD)

ADDRESS OF COURT (City, State, and Zip Code)

MARRIAGE

3.

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.

Specify amount per mo./yr.

STREET

ZIP CODE

CITY

STATE

$

4.

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

Dependent’s monthly

Dependent’s monthly

NAME(S) OF DEPENDENT(S) (Last, first, middle initial)

my contribution

income from other

living expenses

$

$

$

sources

3

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:

ADDRESS OF FORMER SPOUSE

TYPE OF DECREE

DIVORCE DECREE GRANTED BY

STREET

Final

NAME OF COURT

STATE

DATE (YYMMDD)

Interlocutory

NAME OF PERSON FORMER SPOUSE REMARRIED (If applicable)

CITY

STATE

ZIP CODE

Date decree is final

(Last, first, middle initial)

(YYMMDD)

6.

Have any of the above named dependents served as a member of the uniformed services or

YES

NO

participated in full time training duty with pay after the date shown in item 1 above?

YES

NO

DATE LAST APPLICATION FILED (YYMMDD) :

7.

FIRST APPLICATION

I will immediately notify the appropriate officer of any change in the

8.

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

CURRENT DATE

maximum imprisonment of 5 years or both (18 U.S.C. 287-1001.)

(YYMMDD)

CURRENT DATE

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

(YYMMDD)

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:

(YYMMDD).

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