navmc 10922 dd1751

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