navmc 10922 dd1751

DEPENDENCY APPLICATION (1751)NAVMC 10922 (REV. 4-01) (EF)FOUO - Privacy Sensitive when filled in.(Supersedes all previous editions which are obsoleteand will not be used)INSTRUCTIONSWHERE ADDITIONAL SPACE ISNECESSARY TO COMPLETE ITEMS,DATE OF APPLICATIONREASON FOR THIS APPLICATION(CHECK ONE)STARTCHANGE IN DEPENDENTS(Check one)LOSS (EXPLAIN INCERTIFICATION SECTION)GxGAINSECTION 1.NAME OF MARINE (Last, first, middle) SSN GRADE TYPE OF SERVICEUSMCORGANIZATION AND STATION PREPARING THIS APPLICATIONFUTURE ADDRESS AND ETA IF TRANSFER IS ANTICIPATED WITHIN 60 DAYSUNIT RUCECCUSMCRDATE OF CURRENT ENLISTMENT/APPOINTMENTOR DATE REPORTING FOR ACTIVE DUTY(WHICHEVER IS LATER)DATE OF LAST DISCHARGE OR DATE OF LASTRELEASE TO INACTIVE DUTYSECTION 2 DEPENDENT INFORMATIONNO.12345NAME OF DEPENDENT(Include full given name)COMPLETE ADDRESS(Include Zip Code)RELATIONSHIP(if child, indicate step,adopted, ward or born out)DATE OFBIRTH(Day, Mo., Year)DATE ALLOWANCECLAIMED FROM (Ifpreviously approved,give date of approval)6Furnish the following information concerning custodian of any dependent named above.SECTION 3DEPNOFULL NAME OF CUSTODIANRELATIONSHIP TODEPENDENTADDRESS AND ZIP CODESECTION 4 MARITAL OF SERVICE MEMBER AND SPOUSE ANDINFORMATION REGARDING SUPPORT/PATERNITYINFORMATION CONCERNING PRESENT MARRIAGEDATE PLACE (County and State) FULL GIVEN NAME OF SPOUSEHAVE YOU BEEN PREVIOUSLYMARRIED?NO OFNO YESTIMESHAS PRESENT SPOUSE BEENPREVIOUSLY MARRIED?INFORMATION CONCERNING DISSOLUTION OF EACH FORMER MARRIAGE OF BOTH YOURSELF AND/OR SPOUSE (Continue on separate sheet if necessary)FORMERMARRIAGE OFYOUR-SPOUSENAME OF THE SPOUSE INTHE DISSOLVED MARRIAGEDATE OFDISSOLUTIONPlace of dissolution(County and State)IS THERE A COURT ORDER OR WRITTEN AGREEMENT IN EFFECT RELATIVE TO SUPPORT/MAINTENANCE/PATERNITY?NOYESNODEATHIF YES, STATE DATE AND PLACE (county and state) WHERE SUCH ORDER/AGREEMENT WAS ISSUED AND ATTACH A COPY.YESIF EITHER ANSWER ABOVE IS "YES", GIVE INFORMATION REQUESTED BELOW.REASON (Check one)NO OFTIMESANNULMENT DIVORCEORIGINALAdobe Designer 8.0

DEPENDENCY APPLICATION (1751)NAVMC 10922 (REV. 4-01) (EF)FOUO - Privacy Sensitive when filled in.(Supersedes all previous editions which are obsoleteand will not be used)SECTION 1.NAME OF MARINE (Last, first, middle)ORGANIZATION AND STATION PREPARING THIS APPLICATIONINSTRUCTIONSWHERE ADDITIONAL SPACE ISNECESSARY TO COMPLETE ITEMS,DATE OF APPLICATIONSSNFUTURE ADDRESS AND ETA IF TRANSFER IS ANTICIPATED WITHIN 60 DAYSUNIT RUCECCREASON FOR THIS APPLICATION(CHECK ONE)STARTGRADECHANGE IN DEPENDENTS(Check one)LOSS (EXPLAIN INCERTIFICATION SECTION)TYPE OF SERVICEUSMCGxGAINUSMCRDATE OF CURRENT ENLISTMENT/APPOINTMENTOR DATE REPORTING FOR ACTIVE DUTY(WHICHEVER IS LATER)DATE OF LAST DISCHARGE OR DATE OF LASTRELEASE TO INACTIVE DUTYSECTION 2 DEPENDENT INFORMATIONNO.12345NAME OF DEPENDENT(Include full given name)COMPLETE ADDRESS(Include Zip Code)RELATIONSHIP(if child, indicate step,adopted, ward or born out)DATE OFBIRTH(Day, Mo., Year)DATE ALLOWANCECLAIMED FROM (Ifpreviously approved,give date of approval)6Furnish the following information concerning custodian of any dependent named above.SECTION 3DEPNOFULL NAME OF CUSTODIANRELATIONSHIP TODEPENDENTADDRESS AND ZIP CODESECTION 4 MARITAL OF SERVICE MEMBER AND SPOUSE ANDINFORMATION REGARDING SUPPORT/PATERNITYINFORMATION CONCERNING PRESENT MARRIAGEDATE PLACE (County and State) FULL GIVEN NAME OF SPOUSEFORMERMARRIAGE OFYOUR- SPOUSEIS THERE A COURT ORDER OR WRITTEN AGREEMENT IN EFFECT RELATIVE TO SUPPORT/MAINTENANCE/PATERNITY?NOYESNAME OF THE SPOUSE INTHE DISSOLVED MARRIAGEDATE OFDISSOLUTIONHAVE YOU BEEN PREVIOUSLYMARRIED?NO OFNO YESTIMESPlace of dissolution(County and State)HAS PRESENT SPOUSE BEENPREVIOUSLY MARRIED?IF YES, STATE DATE AND PLACE (county and state) WHERE SUCH ORDER/AGREEMENT WAS ISSUED AND ATTACH A COPY.NODEATHYESIF EITHER ANSWER ABOVE IS "YES", GIVE INFORMATION REQUESTED BELOW.INFORMATION CONCERNING DISSOLUTION OF EACH FORMER MARRIAGE OF BOTH YOURSELF AND/OR SPOUSE (Continue on separate sheet if necessary)REASON (Check one)NO OFTIMESANNULMENT DIVORCEDUPLICATE Adobe Designer 8.0

DEPENDENCY APPLICATION (1751)NAVMC 10922 (REV. 4-01) (EF)FOUO - Privacy Sensitive when filled in.(Supersedes all previous editions which are obsoleteand will not be used)SECTION 1.NAME OF MARINE (Last, first, middle)ORGANIZATION AND STATION PREPARING THIS APPLICATIONINSTRUCTIONSWHERE ADDITIONAL SPACE ISNECESSARY TO COMPLETE ITEMS,DATE OF APPLICATIONSSNFUTURE ADDRESS AND ETA IF TRANSFER IS ANTICIPATED WITHIN 60 DAYSUNIT RUCECCREASON FOR THIS APPLICATION(CHECK ONE)STARTGRADECHANGE IN DEPENDENTS(Check one)LOSS (EXPLAIN INCERTIFICATION SECTION)GxGAINTYPE OF SERVICEUSMCUSMCRDATE OF CURRENT ENLISTMENT/APPOINTMENTOR DATE REPORTING FOR ACTIVE DUTY(WHICHEVER IS LATER)DATE OF LAST DISCHARGE OR DATE OF LASTRELEASE TO INACTIVE DUTYSECTION 2 DEPENDENT INFORMATIONNO.12345NAME OF DEPENDENT(Include full given name)COMPLETE ADDRESS(Include Zip Code)RELATIONSHIP(if child, indicate step,adopted, ward or born out)DATE OFBIRTH(Day, Mo., Year)DATE ALLOWANCECLAIMED FROM (Ifpreviously approved,give date of approval)6Furnish the following information concerning custodian of any dependent named above.N 3SECTIODEPNOFULL NAME OF CUSTODIANRELATIONSHIP TODEPENDENTADDRESS AND ZIP CODESECTION 4 MARITAL OF SERVICE MEMBER AND SPOUSE ANDINFORMATION REGARDING SUPPORT/PATERNITYINFORMATION CONCERNING PRESENT MARRIAGEDATE PLACE (County and State) FULL GIVEN NAME OF SPOUSEFORMERMARRIAGE OFYOUR-SPOUSEIS THERE A COURT ORDER OR WRITTEN AGREEMENT IN EFFECT RELATIVE TO SUPPORT/MAINTENANCE/PATERNITY?NOYESNAME OF THE SPOUSE INTHE DISSOLVED MARRIAGEDATE OFDISSOLUTIONHAVE YOU BEEN PREVIOUSLYMARRIED?NO OFNO YESTIMESPlace of dissolution(County and State)HAS PRESENT SPOUSE BEENPREVIOUSLY MARRIED?IF YES, STATE DATE AND PLACE (county and state) WHERE SUCH ORDER/AGREEMENT WAS ISSUED AND ATTACH A COPY.NODEATHYESIF EITHER ANSWER ABOVE IS "YES", GIVE INFORMATION REQUESTED BELOW.INFORMATION CONCERNING DISSOLUTION OF EACH FORMER MARRIAGE OF BOTH YOURSELF AND/OR SPOUSE (Continue on separate sheet if necessary)REASON (Check one)NO OFTIMESANNULMENT DIVORCETRIPLICATE Adobe Designer 8.0

NAVMC 10922 (Rev. 4-01) (EF) Page 2FOUO - Privacy Sensitive when filled in.NAME OF MARINE (Last, first, middle)SECTION 5 NATURAL PARENT OFCHILD IN ARMED FORCESHAS NATURAL PARENT OTHER THAN CLAIMANT OF CHILD( REN) LISTED EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?NOYESIF YES, LIST ALL AVAILABLE IDENTIFYING INFORMATION (Full name of natural parent, SSN, grade, type of service, branchof service, inclusive dates of active service, and full name of child(ren).SECTION 6 SPOUSE IN ARMED FORCESHAS YOUR SPOUSE EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?NOYES IF YES, COMPLETE THE BLOCKS BELOW.SSN GRADE TYPE OF SERVICE BRANCH OF SERVICE INCLUSIVE DATES OF ACTIVE SERVICE BAQREGULARRESERVEWITH DEPENDENTSWITHOUT DEPENDENTSSECTION 7 CERTIFICATIONI CERTIFY that all the above statements are true to the best of myknowledge and belief, and I consent to checkage against my pay for anyallowances paid on laws and regulations. I will immediately inform myCommanding Officer of any change in the number and/or status of mydependents, whether it be the gain of additional dependents, or the lossof dependents.Subscribed and swornbefore me this day of 20By signing this form, I hereby authorize release of any information hereonor obtained as a result of the processing/adjudication of this application, tomy claimed dependents or custodians thereof, to the extent necessary forthe proper adjudication of benefits, entitlements and/or of my legalobligation to support my dependents.(Signature of Marine) (Social Security Number) (Grade)(Signature and Title of Attesting Officer )Document ViewedSECTION 8 APPROVING AUTHORITYFOR USE BY COMMAND APPROVING AUTHORITY:APPROVED ASCLAIMEDAPPROVED FORDEPENDENTNUMBERS:APPROVED FOR CHILD BORNOUT OF WEDLOCK FOR DEERSELIGIBILITY PER MCOP5512.11. CHECK ONECHILDRESIDES INMEMBER'SHOUSEHOLD(Recertify annually)No Court Order(Signature of Commanding Officer)FORWARDED TO CMC(CODE MRP-1) FORAPPROVAL FORDEPENDENT NUMBERSCOURTORDERFOR USE BY UNIT DIARY CLERK:REPORTED ON UNIT DUTY:NO.DATEDRUCENTRIES REPORTED:FOR USE BY CMC APPROVING AUTHORITY:(Typed Name and Grade of Commanding Officer)(Unit Designation)ORIGINAL

NAVMC 10922 (Rev. 4-01) (EF) Page 2FOUO - Privacy Sensitive when filled in.NAME OF MARINE (Last, first, middle)SECTION 5 NATURAL PARENT OFCHILD IN ARMED FORCESHAS NATURAL PARENT OTHER THAN CLAIMANT OF CHILD( REN) LISTED EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?NOYESIF YES, LIST ALL AVAILABLE IDENTIFYING INFORMATION (Full name of natural parent, SSN, grade, type of service, branchof service, inclusive dates of active service, and full name of child(ren).SECTION 6 SPOUSE IN ARMED FORCESHAS YOUR SPOUSE EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?NOYES IF YES, COMPLETE THE BLOCKS BELOW.SSN GRADE TYPE OF SERVICE BRANCH OF SERVICE INCLUSIVE DATES OF ACTIVE SERVICE BAQREGULARRESERVEWITH DEPENDENTSWITHOUT DEPENDENTSSECTION 7 CERTIFICATIONI CERTIFY that all the above statements are true to the best of myknowledge and belief, and I consent to checkage against my pay for anyallowances paid on laws and regulations. I will immediately inform myCommanding Officer of any change in the number and/or status of mydependents, whether it be the gain of additional dependents, or the lossof dependents.Subscribed and swornbefore me this day of 20By signing this form, I hereby authorize release of any information hereonor obtained as a result of the processing/adjudication of this application, tomy claimed dependents or custodians thereof, to the extent necessary forthe proper adjudication of benefits, entitlements and/or of my legalobligation to support my dependents.(Signature of Marine) (Social Security Number) (Grade)(Signature and Title of Attesting Officer )Document ViewedSECTION 8 APPROVING AUTHORITYFOR USE BY COMMAND APPROVING AUTHORITY:APPROVED ASCLAIMEDAPPROVED FORDEPENDENTNUMBERS:APPROVED FOR CHILD BORNOUT OF WEDLOCK FOR DEERSELIGIBILITY PER MCOP5512.11. CHECK ONECHILDRESIDES INMEMBER'SHOUSEHOLD(Recertify annually)No Court Order(Signature of Commanding Officer)FORWARDED TO CMC(CODE MRP-1) FORAPPROVAL FORDEPENDENT NUMBERSCOURTORDERFOR USE BY UNIT DIARY CLERK:REPORTED ON UNIT DUTY:NO.DATEDRUCENTRIES REPORTED:FOR USE BY CMC APPROVING AUTHORITY:(Typed Name and Grade of Commanding Officer)(Unit Designation)DUPLICATE

NAVMC 10922 (Rev. 4-01) (EF) Page 2FOUO - Privacy Sensitive when filled in.NAME OF MARINE (Last, first, middle)SECTION 5 NATURAL PARENT OFCHILD IN ARMED FORCESHAS NATURAL PARENT OTHER THAN CLAIMANT OF CHILD( REN) LISTED EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?NOYESIF YES, LIST ALL AVAILABLE IDENTIFYING INFORMATION (Full name of natural parent, SSN, grade, type of service, branchof service, inclusive dates of active service, and full name of child(ren).SECTION 6 SPOUSE IN ARMED FORCESHAS YOUR SPOUSE EVER BEEN A MEMBER OF ANY U.S. ARMED FORCE?NOYES IF YES, COMPLETE THE BLOCKS BELOW.SSN GRADE TYPE OF SERVICE BRANCH OF SERVICE INCLUSIVE DATES OF ACTIVE SERVICE BAQREGULARRESERVEWITH DEPENDENTSWITHOUT DEPENDENTSSECTION 7 CERTIFICATIONI CERTIFY that all the above statements are true to the best of myknowledge and belief, and I consent to checkage against my pay for anyallowances paid on laws and regulations. I will immediately inform myCommanding Officer of any change in the number and/or status of mydependents, whether it be the gain of additional dependents, or the lossof dependents.Subscribed and swornbefore me this day of 20By signing this form, I hereby authorize release of any information hereonor obtained as a result of the processing/adjudication of this application, tomy claimed dependents or custodians thereof, to the extent necessary forthe proper adjudication of benefits, entitlements and/or of my legalobligation to support my dependents.(Signature of Marine) (Social Security Number) (Grade)(Signature and Title of Attesting Officer )Document ViewedSECTION 8 APPROVING AUTHORITYFOR USE BY COMMAND APPROVING AUTHORITY:APPROVED ASCLAIMEDAPPROVED FORDEPENDENTNUMBERS:APPROVED FOR CHILD BORNOUT OF WEDLOCK FOR DEERSELIGIBILITY PER MCOP5512.11. CHECK ONECHILDRESIDES INMEMBER'SHOUSEHOLD(Recertify annually)No Court Order(Signature of Commanding Officer)FORWARDED TO CMC(CODE MRP-1) FORAPPROVAL FORDEPENDENT NUMBERSCOURTORDERFOR USE BY UNIT DIARY CLERK:REPORTED ON UNIT DUTY:NO.DATEDRUCENTRIES REPORTED:FOR USE BY CMC APPROVING AUTHORITY:(Typed Name and Grade of Commanding Officer)(Unit Designation)TRIPLICATE