Dd Form 137-6, Dependency Statement - Full Time Student 21 - 22 Years Of Age Page 4

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14. REMARKS

(Use a separate sheet of paper if necessary)

READ THE PENALTY PROVISIONS, SIGN AND DATE THE FORM, AND HAVE IT NOTARIZED.

NOTE: Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or

covers up by any trick, scheme, or device, a material fact, or makes any false, fictitious, or fraudulent statements or representations, or makes or

uses any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry, shall be fined as provided in Title

18, or imprisoned not more than 5 years, or both (U.S. Code, title 18, section 1001). The information provided in this form may be referred to the

appropriate Military Service investigative agency.

I make the foregoing claim with full knowledge of the penalties involved for willfully making a false claim. (U.S. Code, title 18, section

287, formerly section 80, provides a penalty as follows: Imprisonment for not more than five years and subject to a fine in the amount

provided in this title.)

15. SIGNATURES

a. MEMBER, STUDENT, OR CUSTODIAN OF STUDENT

(print name(s)) will immediately notify

I/we

the service concerned of any change in child's financial circumstances, marital status, physical custody, or change in dependency upon the service

member as shown in this form.

(1) SIGNATURE