Dd Form 93, Record Of Emergency Data, August 1998

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RECORD OF EMERGENCY DATA
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 1475 to 1480 and 2771, 38 USC 1970, 44 USC 3101, and EO 9397, November 1943 (SSN).
PRINCIPAL PURPOSES: This form is used to designate beneficiaries for certain benefits in the event of the servicemember's death. It is a
guide for the disposition of that member's pay and allowances if captured, missing or interned. It also shows names and addresses of the
person(s) the servicemember desires to be notified in case of emergency or death. The purpose of soliciting the SSN is to provide positive
identification.
ROUTINE USES: None.
DISCLOSURE: Voluntary; however, failure to provide personal identifier information may delay notification of the servicemember's status or
may handicap processing of benefits to designated beneficiaries.
INSTRUCTIONS TO SERVICEMEMBER
This extremely important form is to be used by you to show
statement carefully, and sign on the line provided:
the names and addresses of your spouse, children, parents, and
any other person(s) you would like notified if you become a
I fully understand that, if I am captured, missing, or interned, my
casualty, and, to designate beneficiaries for certain benefits if
designation of allotments to dependents from my pay and allowances
you die. IT IS YOUR RESPONSIBILITY to keep your Record of
serves only as a guide to the Secretary of my Service. The Secretary may
Emergency Data up to date to show your desires as to bene-
alter my designated allotment in the best interests of myself, my
ficiaries to receive certain death payments, and to show changes
dependents, or the United States Government.
in your family or other dependents listed; for example, as a
result of marriage, civil court action, death, or address change.
Regarding your designation in Item 11, "Allotment if Missing" (if
used by your Service), please read the following
(Signature of Servicemember)
b. INITIAL
1. NAME
2a. SSN
3a. SERVICE
(Last, First, Middle)
b. REPORTING UNIT CODE
(To indicate
DUTY STATION
valid SSN)
4a. SPOUSE NAME
b. ADDRESS (Include ZIP Code)
5. CHILDREN
c. DATE OF BIRTH
b. RELATIONSHIP
d. ADDRESS (Include ZIP Code)
a. NAME
(YYYYMMDD)
6a. FATHER NAME
b. ADDRESS (Include ZIP Code)
7a. MOTHER NAME
b. ADDRESS (Include ZIP Code)
8a. DO NOT NOTIFY DUE TO ILL HEALTH
b. NOTIFY INSTEAD
9a. BENEFICIARY(IES) FOR DEATH GRATUITY
(If no surviving
b. ADDRESS (Include ZIP Code)
c. PERCENTAGE
spouse or child)
10a. BENEFICIARY(IES) FOR UNPAID PAY/ ALLOWANCES
b. ADDRESS (Include ZIP Code)
c. PERCENTAGE
11. ALLOTMENT DESIGNEE/PERCENTAGE IF MISSING
(Subject to Secretarial determination)
a. SGLI (Optional Service Use)
b. INSURANCE COMPANIES/POLICY NUMBERS
12. INSURANCE
(SGLI and
other Insurance Com-
MAXIMUM
NO
panies/Policy Numbers)
OTHER (Amount)
13. CONTINUATION/REMARKS
14. SIGNATURE OF SERVICEMEMBER
15. SIGNATURE OF WITNESS
16. DATE SIGNED
(Include rank, rate, or grade)
(Include rank, rate, or grade)
(YYYYMMDD)
DD FORM 93, AUG 1998
PREVIOUS EDITION MAY BE USED.
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