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14. DEPENDENT RELATIONSHIP (Enter one of the following codes)

NOTE: If code selected is B, complete all of Item 15. If code C, K. S, T, or W, complete 15c. only. If code A, D, I, L, or R, do not complete Item

15.

WITHOUT DEPENDENT(S)

WITH DEPENDENT OTHER THAN CHILD(REN)

WITH DEPENDENT CHILD(REN)

I - Instructor married to

A - Spouse

B - Child in legal custody of

T - Handicapped child

instructor

D - Parent (including "In Loco Parentis"

someone other than instructor

(over age 21)

R - Own right (single)

which is a person who stood in place

C - Child in instructor's custody

W - Instructor married

of the natural parents)

K - Ward

to instructor with

L - Parent(s)-in-law

S - Student (age 21 - 22)

dependent child(ren)

15. IF CLAIMING DEPENDENT CHILD(REN)

a. WHO HAS CUSTODY OF CHILD(REN)?

b. IF IN CUSTODY OF FORMER SPOUSE, AND FORMER SPOUSE IS ACTIVE DUTY OR INSTRUCTOR:

(1) DoD ID NUMBER

(2) DUTY LOCATION

INSTRUCTOR

FORMER SPOUSE

OTHER

c. DATE OF BIRTH OF YOUNGEST CHILD

d. IF YOU DO NOT HAVE CUSTODY, DO YOU PAY CHILD SUPPORT?

CLAIMED AS A DEPENDENT (YYYYMMDD)

IF "YES", INDICATE MONTHLY AMOUNT PAID

YES

SUPPORTING DOCUMENTATION REQUIRED FOR ORIGINAL CERTIFICATION OF BAH

CERTIFICATION OF DEPENDENT(S)

1. Spouse - copy of marriage certificate with seal.

2. Child(ren) - copy of birth certificate with seal.

3. Child(ren) not in instructor's custody - divorce decree, legal separation agreement, court order.

SECONDARY DEPENDENT(S)

1. Parent(s) or parent(s)-in-law - court order of guardianship.

2. Ward - Court order of guardianship.

3. Student (age 21 - 22 in school) - letter from learning instutution verifying full time enrollment.

4. Handicapped child over age 21 - medical sufficiency statement.

VERIFICATION OF GOVERNMENT/EMPLOYER PROVIDED QUARTERS ASSIGNED

1. Letter from housing office if assigned to active duty spouse, or

2. Certification letter from school.

PART B

SECTION I - OHA (Applies to Overseas Locations Only)

b. IF YES, NUMBER OF SHARERS

16. ACCOMPANIED (X one)

17a. SHARER (X one)

YES

18a. RENTER STATUS (X one)

b. IF RENTING, PROVIDE RENTAL/LEASE DATES:

(1) FROM (YYYYMMDD)

(2) TO (YYYYMMDD)

RENT

OTHER

OWN

19a. MONTHLY RENT/MORTGAGE PAYMENT

b. TAXES/INSURANCE AMOUNT (If not included in monthly mortgage

c. CURRENCY TYPE

payment)

b. IF "NO", LIST MONTHLY AMOUNT(S) BELOW:

20a. UTILITIES INCLUDED IN MONTHLY

RENT (X one)

(1) WATER

(2) TRASH REMOVAL

(3) ELECTRIC

(4) GAS

YES

21. DUTY LOCATION (City and Country)

SUPPORTING DOCUMENTATION REQUIRED FOR OHA (Original Certification and Recertification)

1. Copy of rental lease, or proof of mortgage payment amount (copy of payment coupon).

2. Evidence of real estate taxes, and homeowner insurance costs, if not included in mortgage payment if renter status in 18.a. is marked "Own".

SECTION II - COLA (Applies to Overseas Locations, Alaska and Hawaii Only)

22. NUMBER OF DEPENDENTS RESIDING

23. JTR LOCATION (To be filled out by pay technician)

WITH INSTRUCTOR

CERTIFICATION

I certify that the information provided is true and correct. Entitlements will not be included in the applicable pay computation without this verification

and certification of eligibility.

SIGNATURE OF INSTRUCTOR

DATE SIGNED

DD FORM 2754 (BACK), DEC 2017

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Dd Form 2754 - Jrotc Instructor Pay Certification Worksheet For Entitlement Computation Page 2

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