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<tr class="odd">
<td colspan="3"><p>PHS-1637-1</p>
<p>REV. 8/05</p></td>
<td colspan="19"><p id="department-of-health-and-human-services"
class="heading"> DEPARTMENT OF HEALTH AND HUMAN SERVICES</p>
<p id="public-health-service-commissioned-officers-request-for"
class="heading"> PUBLIC HEALTH SERVICE COMMISSIONED OFFICER’S REQUEST
FOR</p>
<h4 id="dependency-determination"> DEPENDENCY DETERMINATION</h4></td>
<td colspan="2" rowspan="3"><p id="payroll-use-only"
class="heading">PAYROLL USE ONLY</p></td>
</tr>
<tr class="even">
<td colspan="4"><p>SOCIAL SECURITY NUMBER (SSN)</p>
<p>     </p></td>
<td colspan="12"><p>NAME <em>(LAST, FIRST, MIDDLE INITIAL)</em></p>
<p>     </p></td>
<td colspan="6"><p>DATE OF LAST ENTRY ON ACTIVE DUTY</p>
<p><em>(IF RETIRED, LIST DATE OF RETIREMENT INSTEAD)</em></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>CURRENT</p>
<p>PAY GRADE</p>
<p>     </p></td>
<td colspan="12"><p>CURRENT DUTY STATION <em>(IF RETIRED, LIST CURRENT
MAILING ADDRESS AND ZIP CODE)</em></p>
<p>     </p></td>
<td colspan="8"><p>DUTY STATION TELEPHONE</p>
<p><em>(IF RETIRED, LIST CURRENT HOME PHONE AND AREA CODE)</em></p>
<p>(     )      </p></td>
</tr>
<tr class="even">
<td><strong>1.</strong></td>
<td colspan="23">PURPOSE Establish Initial Dependency Re-Certification
of Dependency Date of Last Certificate <u>     </u></td>
</tr>
<tr class="odd">
<td colspan="24"><p id="dependency-information"
class="heading">DEPENDENCY INFORMATION</p></td>
</tr>
<tr class="even">
<td><strong>2.</strong></td>
<td colspan="23">MARITAL STATUS Married <em>(Includes Separated)</em>
Single <em>(Includes Widowed)</em> Divorced</td>
</tr>
<tr class="odd">
<td><strong>3.</strong></td>
<td colspan="23">a. I hereby claim the following dependents<br />
effective: <u>     </u> <em>(See Notes 1, 2, and 3)</em></td>
</tr>
<tr class="even">
<td></td>
<td colspan="10"><p>b. NAME(S) OF DEPENDENT(S) <em>(Last, First, Middle
Initial)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8"><p>COMPLETE ADDRESS <em>(Include Zip Code)</em></p>
<p>     </p></td>
<td colspan="4"><p>RELATIONSHIP</p>
<p>     </p></td>
<td><p>DATE OF BIRTH</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="10"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="10"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9"><p>DATE AND PLACE OF PRESENT MARRIAGE</p>
<p>     </p></td>
<td colspan="14"><p>IF THIS IS THE FIRST TIME YOU HAVE CLAIMED AN
ADOPTED CHILD, SHOW DATE OF ADOPTION AND ADDRESS</p>
<p>OF COURT ISSUING DECREE <em>(See Note 1)</em></p>
<p>     </p></td>
</tr>
<tr class="even">
<td><strong>4.</strong></td>
<td colspan="23">IF ANY CHILD(REN) NAMED ABOVE IS (ARE) NOT IN YOUR
LEGAL CUSTODY, COMPLETE THE FOLLOWING:</td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td colspan="5"><p>NAME(S) OF CHILD(REN)</p>
<p>     </p></td>
<td colspan="11" rowspan="2"><p>NAME AND ADDRESS OF PERSON HAVING LEGAL
CUSTODY</p>
<p>     </p></td>
<td colspan="7"><p>AMOUNT OF YOUR MONTHLY CONTRIBUTION FOR SUPPORT
OF</p>
<p>CHILD(REN)</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5"><p>RELATIONSHIP OF CUSTODIAN TO CHILD(REN)</p>
<p>     </p></td>
<td colspan="7"><p>IF SUPPORT OF CHILD(REN) IS REQUIRED BY COURT ORDER
OR</p>
<p>DIVORCE DECREE, SHOW AMOUNT OF SUPPORT REQUIRED</p>
<p><em>(See Note 1)</em>      </p></td>
</tr>
<tr class="odd">
<td><strong>5.</strong></td>
<td colspan="23">COMPLETE THIS SECTION ONLY IF DEPENDENT(S) LISTED IN
ITEM 3 ABOVE ARE OTHER THAN YOUR LAWFUL SPOUSE AND/OR UNMARRIED
CHILD(REN) UNDER 21 YEARS OF AGE:<br />
<em>(See Note 2)</em></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6"><p>NAME(S) OF DEPENDENT(S)</p>
<p>     </p></td>
<td colspan="6"><p>MONTHLY AMOUNT OF CONTRIBUTION</p>
<p>     </p></td>
<td colspan="6"><p>DEPENDENT’S INCOME FROM OTHER SOURCES</p>
<p>     </p></td>
<td colspan="5"><p>DEPENDENT’S MONTHLY EXPENSES</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="6">     </td>
<td colspan="6">     </td>
<td colspan="6">     </td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="14">I did did not claim the above-named dependent(s) on my
Federal Income Tax return for the past calendar year.</td>
<td colspan="6"><p>INTERNAL REVENUE OFFICE AT WHICH LAST</p>
<p>FEDERAL INCOME TAX RETURN WAS FILED.</p></td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="23"><p>REASON DEPENDENT(S) WAS (WERE) NOT CLAIMED FOR
FEDERAL INCOME TAX PURPOSES:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="23">FOR UNMARRIED CHILD OVER 21 YEARS OF AGE EITHER
PHYSICALLY OR MENTALLY HANDICAPPED, ATTACH A STATEMENT FROM A PHYSICIAN
SHOWINGHOW LONG THE CHILD HAS<br />
BEEN UNDER A PHYSICIAN’S CARE AND THE CAUSE AND DEGREE OF
INCAPACITATION. IF THE CHILD IS IN THE CUSTODY OF SOMEONE OTHER THAN THE
OFFICER, A STATEMENT<br />
SIGNED BY THE CUSTODIAN SHOWING AMOUNT OF OFFICER’S CONTRIBUTION AND
ACTUAL MONTHLY EXPENSES OF THE CHILD IS ALSO REQUIRED.</td>
</tr>
<tr class="odd">
<td><strong>6.</strong></td>
<td colspan="23">IF DIVORCED, SHOW THE FOLLOWING:</td>
</tr>
<tr class="even">
<td rowspan="2"></td>
<td colspan="7"><p>DIVORCE DECREE GRANTED BY <em>(Court, State,
Date):</em></p>
<p><em>(See Note 1)</em>      </p></td>
<td colspan="9" rowspan="2"><p>ADDRESS OF FORMER SPOUSE <em>(Include Zip
Code)</em></p>
<p>     </p></td>
<td colspan="7" rowspan="2"><p>TYPE OF DECREE:</p>
<blockquote>
<p> Final Interlocutory</p>
<p>Date Decree is Final: <u>     </u></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="7"><p>FULL NAME OF PERSON FORMER SPOUSE REMARRIED</p>
<p>     </p></td>
</tr>
<tr class="even">
<td><strong>7.</strong></td>
<td colspan="23"><p>HAVE ANY OF THE ABOVE-NAMED DEPENDENTS SERVED AS A
MEMBER OF THE UNIFORMED SERVICES OR PARTICIPATED IN FULL-TIME DUTY SINCE
YOUR DATE OF LAST ENTRY ON</p>
<p>ACTIVE DUTY? Yes No IF "Yes," COMPLETE THE FOLLOWING:</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"><p>NAME(S) OF DEPENDENT(S)</p>
<p>     </p></td>
<td colspan="7"><p>SSN OF DEPENDENT(S)</p>
<p>     </p></td>
<td colspan="3"><p>BRANCH OF SERVICE</p>
<p>     </p></td>
<td colspan="5"><p>PERIOD OF SERVICE</p>
<p>From: <u>     </u></p>
<p>Through: <u>     </u></p></td>
<td colspan="4"><p>DUTY STATION</p>
<p>     </p></td>
</tr>
<tr class="even">
<td><strong>8.</strong></td>
<td colspan="23"><p>DID THE DEPENDENT(S) LISTED IN ITEM 3 ABOVE, OCCUPY
GOVERNMENT QUARTERS OR HOUSING FACILITIES WITHOUT CHARGE EXCEPT FOR
BRIEF PERIODS IN QUARTERS</p>
<p>ASSIGNED TO ANOTHER UNIFORMED SERVICE MEMBER FROM THE EFFECTIVE DATE
SPECIFIED ABOVE?</p>
<p> Yes No IF "Yes," COMPLETE THE FOLLOWING:</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"><p>NAME(S) OF DEPENDENT(S)</p>
<p>     </p></td>
<td colspan="9"><p>FROM: TO:</p>
<p>           </p></td>
<td colspan="6"><p>LOCATION OF QUARTERS:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td><strong>9.</strong></td>
<td colspan="23"><strong>IMPORTANT: Making a false statement or claim
against the U.S. Government is punishable by fine of not more than
$10,000 or imprisonment for not more than 5 years, or both (18 U.S.C.
287 and 1001).</strong></td>
</tr>
<tr class="odd">
<td><strong>10.</strong></td>
<td colspan="23">I will immediately notify the Office of Commissioned
Corps Support Services, ATTN: Compensation Branch, Room 4-50, 5600
Fishers Lane, Rockville, MD 20857-0001, of any change in the dependency
status of my dependent(s) OR if I am assigned to or released from
assignment to Government quarters. I certify that the facts I have
stated in connection with this request are true and correct to the best
of my knowledge.</td>
</tr>
<tr class="even">
<td></td>
<td colspan="10">CURRENT DATE</td>
<td colspan="13">SIGNATURE OF OFFICER</td>
</tr>
<tr class="odd">
<td colspan="24"><blockquote>
<p><em><strong>NOTE:</strong></em> 1. Attach a copy of the court order
or divorce decree if this is your first certificate or if the
adoption/divorce has occurred subsequent to the date of your last
certificate.<br />
2. A complete form PHS-1637-2, <em>"Parent’s/ Parent-In-Law’s Dependency
Statement,"</em> must be attached to this form if you claim a parent /
parent-in-law as a dependent<em>.<br />
</em>3. A complete form PHS-1637-4, <em>"Child’s Dependency
Statement,"</em> must be attached to this form if you claim a child(ren)
and are divorced / separated from the child(ren)’s other parent.</p>
</blockquote></td>
</tr>
</tbody>
</table>

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**PUBLIC HEALTH SERVICE COMMISSIONED CORPS**

**INSTRUCTIONS FOR COMPLETING FORM**

**PHS-1637-1**

**GENERAL:** Read the instructions and Privacy Act statement below
before completing the form. All responses should be typed\
or printed in ink. Submit completed form to:

> Office of Commissioned Corps Support Services
>
> ATT: Compensation Branch
>
> 5600 Fishers Lane, Room 4-50
>
> Rockville, MD 20857-0001

**HEADING:** Applicable to all Public Health Service (PHS) Commissioned
Corps officers. Self-explanatory.

**Item 1:** Place an \"X\" in the box(es) which identifies the action(s)
being requested.

**Item 2:** Self-explanatory.

**Item 3:** a. Effective date to be entered is the latest of the
following dates:

> 1\. call to active-duty date;
>
> 2\. date of marriage;
>
> 3\. date individual became an eligible dependent pursuant to
> established policy;
>
> 4\. date Government quarters were terminated; or

5\. if the purpose of submitting the form is \"Recertification\" and the
last digit of your SSN is 1, enter \"1\
Jan \_\_\_\_\_ (year)\"; 2, enter \"1 Feb \_\_\_\_\_ (year)\"; 3, enter
\"1 Mar \_\_\_\_\_ (year)\"; 4, enter \"1 Apr \_\_\_\_\_\
(year)\"; 5, enter \"1 May \_\_\_\_\_ (year)\"; 6, enter \"1 Jun
\_\_\_\_\_ (year)\"; 7, enter \"1 Jul \_\_\_\_\_ (year)\"; 8,\
enter \"1 Aug \_\_\_\_\_ (year)\"; 9, enter \"1 Sep \_\_\_\_\_ (year)\";
0, enter \"1 Oct \_\_\_\_\_ (year)\".

b\. Enter all eligible dependents. If the address is the same for all
dependents, list only once. If additional space is\
required, identify dependents on a separate sheet of paper and attach
the paper to this form. Include sponsor's\
name and SSN.

**Item 4:** Complete only if child(ren) listed in Item 3 is/are not in
the officer's legal custody.

**Item 5:** Complete only if dependent(s) listed in Items 3 is/are other
than the officer's legal spouse and/or dependent child(ren)\
under 21 years of age. Dependent's income from other sources must
include all wages, compensation, pensions,\
annuities, alimony, retirement benefits, and the reasonable value of
gifts and contributions received from others.\
Dependent's monthly expenses should only reflect the dependent's average
living expenses during the past calendar\
year which can be documented. You may include a reasonable value for
quarters and/or subsistence furnished by\
someone other than the dependent. (Reference Commissioned Corps
Personnel Manual, Subchapter CC22.)

**Item 6:** Complete only if divorced and dependent(s) is/are identified
in Item 3.

**Item 7:** Complete only if dependent(s) is/are listed in Item 3. The
uniformed services include the Army, Navy, Air Force,\
Marines, Coast Guard, Commissioned Corps of the National Oceanic and
Atmospheric Administration, and PHS\
Commissioned Corps.

**Item 8:** Self-explanatory.

**Item 9:** Self-explanatory.

**Item 10:** Self-explanatory.

**PRIVACY ACT NOTICE FOR**

**PHS COMMISSIONED OFFICER'S REQUEST FOR DEPENDENCY DETERMINATION**

**FORM PHS-1637-1**

This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C.
552a). Our authority to collect this information is 37 U.S.C. 403;\
42 U.S.C. 202 et seq.; and Executive Order 9397, \"Numbering System for
Federal Accounts Relating to Individual Persons.\"

The information provided on this form will become part of record systems
09-40-0001, \"PHS Commissioned Corps Personnel Records,\"\
HHS/PSC/HRS and 09-40-0010, \"Pay, Leave, and Attendance Records,\"
HHS/PSC/HRS.

*PRINCIPAL PURPOSE AND ROUTINE USES* - This information is used to
determine whether an individual's dependency on a PHS\
commissioned officer entitles the officer to additional Basic Allowance
for Housing (BAH). This information will be used only as\
necessary in personnel and pay administration processes carried out in
accordance with established regulations and published notices of\
systems of records. Copies of these systems of records may be obtained
by contacting the office to which you submit this form.

*EFFECTS OF NONDISCLOSURE* - Disclosure of the Social Security Number
(SSN) is mandatory under provisions of Executive Order\
9397 to obtain benefits and services as or on behalf of a commissioned
officer. The SSN is also used to distinguish a record from those of\
commissioned officers who may have similar names and dates of birth.
Failure to provide the remaining information will result in denial of\
this claim, delay and/or errors in determining dependency, late payment
or non-payment, or refund of BAH if payment is based on\
erroneous information. All statements are subject to verification.