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)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