Secondary Dependency:

EXPENSES BREAKDOWN

All expenses listed should be true expenses and not estimates. 

- If amount appears to be excessive additional proof of expense may be 

requested upon processing of claim.

Household Expenses - List ALL expenses related to the home for all persons in the home 

regardless of who pays for them. Do NOT pro-rate these figures to come up with the 

amounts perceived to be the dependent’s portion.

- Rent, mortgage, or FRV - If the dependent resides in the member's household or in a 

dwelling owned by the member, use Fair Rental Value (FRV-see below for the definition) for the 

dwelling. If the dependent does not reside in the member's household or in a dwelling owned 

by the member, list the actual mortgage, rent, or FRV if the dwelling is mortgage-free. If FRV is 

used, give a brief explanation of how the Fair Rental Value was obtained using the Remarks 

section on the last page. However, if the dependent resides in and owns the home mortgage 

free, enter "None" in the expense block for the mortgage/rent/FRV. If the dependent lives with 

someone else in that person’s home and the home is mortgage free use the FRV for the home. 

- - If rent is used a copy of the rental agreement/lease showing who signed as the 

responsible paying party, the monthly rent amount, and if the home is subsidized housing or 

not must be provided.

- - If mortgage is used a copy of the most current dated mortgage statement must be 

provided.

- - If FRV is used the information stating where the amount was obtained must be listed 

on the last page in the remarks or a copy of the documents used to obtain it must be provided.

- - If there is no mortgage on a home that is owned by the dependent then proof of 

ownership of the home without a mortgage is required. (A copy of the deed, etc.)

- -FAIR RENTAL VALUE (FRV): FRV is a single monthly sum for the entire dwelling 

where the parent lives. This sum is an amount the owner can reasonably expect to 

receive from a stranger to rent the dwelling. FRV will not include food, utilities, 

furniture, and home repairs, which are listed separately but does include the tax 

expenses the owner of the home pays.

- Tax & Insurance - List the amount of taxes and insurance paid for the home if 

applicable. If you are paying a mortgage, you will have a figure for both of these. If you are 

renting, you likely only have rental insurance. If you use FRV you will only list the insurance as 

the taxes are part of the FRV expense. If you have a home tax expense and are renting be sure 

that the documents stating you are required to pay the taxes is included in your rental/lease 

agreement and if they are not then be sure to include those additional documents.

- Food - List the entire monthly food bill for ALL persons in the home including eating 

out expenses.
- Utilities - List the full amount of all monthly utility bills. For each utility bill that is over 

$200 per month be sure to provide a copy of the most current dated bill supporting that 

expense. This expense is for gas, electric, water, utilities, and a home phone land line only.

- Furniture/Appliances - This should list the cost of any furniture or appliance item(s) 

purchased for the home within the past year only.

- Repairs - List any expense related to making repairs or renovations to the home within 

the last year.

- Other - This expense includes all household related expenses that are not already 

accounted for on the form. Examples include lawn maintenance, tree trimming, gutter cleaning, 

security system, cable/internet, trash pickup, HOA fees, pool maintenance, storage units, 

entertainment applications used by the entire household, etc. When using this block, be sure to 

itemize the expenses in the remarks on the 137 by giving a list of each expense along with the 

monthly amount for each one. For each expense listed that is over $200 per month be sure to 

provide a copy of the most current dated bill to support that expense.

Personal Expenses - This section should include only your claimed dependent’s personal 

expenses regardless of who pays for them. If you are claiming more than one dependent such 

as two parents be sure that the expenses reflect the total for both. If your dependent has a 

minor dependent they cannot be claimed by the member as a dependent but the minor’s 

expenses should reflect in the dependent’s expenses with the total for both. 

- Clothing - List average monthly cost associated with clothing purchases.

- Laundry and Dry Cleaning - This includes all expenses associated with keeping your 

claimed dependent’s clothing clean such as cleaning products, laundromat expenses, dry 

cleaning expenses, etc.

- Medical - This is for all out-of-pocket medical expenses not paid by insurance, to 

include co-pays for doctor visits and prescriptions, over the counter medications, first aid items, 

medical equipment, etc.

- Value of USIP card - This is the benefit your dependent receives from having the 

USIP/ID card. If you use this block, you must send in supporting documentation. Examples of 

the realized value and supporting documentation include medical expenses covered by Tricare 

(supported by Explanation of Benefit (EOB) statements from Tricare), value of medical visits to a 

military medical facility (supported by Medical Cost Estimate from the military medical facility’s 

patient administration office), decreased medication costs (supported by either an EOB from 

Tricare or a statement from your pharmacy), or statements from the dependent’s doctor(s) and 

pharmacy showing what they billed, what Tricare paid, and what you were responsible to pay. 

(The amount you show as being responsible to pay is an expense that can also be used in the 

medical expense field.)
- Personal Insurance - Premiums paid for any insurance for your dependent (life, health, 

dental, auto, etc.)

- Personal Taxes - List any taxes your dependent pays. This usually pertains to payroll 

taxes your dependent pays. If there is a tax expense that is not income taxes then you must 

provide a copy of the tax bill to support the amount claimed. (Note: gross amount of income 

(amount before taxes are taken out) should be recorded on page 4)

- Private Auto Payments - Annotate your dependent’s total vehicle payments ONLY for

vehicles registered in their name. This must be accompanied with copies of the most current 

statement for the loan for the auto along with a copy of the registration for that auto.

- Transportation - This includes all expenses related to transporting your claimed 

dependent from one location to another regardless of the destination. This includes bus and 

cab fares as well as gas, oil, tires, maintenance, etc for the vehicle your dependent rides in may 

be included. (Insurance should be claimed in the personal insurance expense field.)

- School Expenses - List all school related expenses your dependent has if they are 

attending school/college. If your claim is for a student, please see further explanation of the 

student expenses below. If the expense is for school loans and the dependent is no longer in 

school they cannot be claimed. If the dependent has a dependent in school those expenses can 

be claimed here. If this box is filled in, documents to support the amount listed is required. 

- Other - Examples of other personal expenses include personal hygiene items, 

entertainment (movies, hobbies, clubs, sports, etc.), haircuts, food items specific to the 

dependent (The food specific to the dependent must be supported by a medical statement 

from their doctor stating they must be on a special diet and require different foods.), storage

unit, dependent’s cell phone (if they are on a bill with someone else then only their portion of 

that bill can be claimed), etc. When using this block, be sure to itemize the expenses in the 

remarks on the 137 by giving a list of each expense along with the monthly amount for each 

one. For each expense listed that is over $200 per month be sure to provide a copy of the most 

current dated bill to supporting that expense.

School Expenses - This section should include claimed dependent’s school expenses 

regardless of who pays for them. All expenses should be listed as a MONTHLY average.

- Tuition - List the full monthly tuition expense.

- Books - List the full monthly book expense.

- Special fees - List any special fees incurred for attending the school or classes (lab fees, 

distance education fees, internship fees, etc.)

- Room - List the monthly rent for room/apartment, etc.
- Board - List student’s monthly food expense. (If room and board is counted as one 

expense on the bill list that amount in the rent and leave the food blank then annotate in the 

remarks on the last page that room and board are one bill.)

- Other School Expenses - Examples include parking pass, school supplies, etc. When 

using this block, be sure to itemize the expenses in the remarks on the 137 by giving a list of 

each expense along with the monthly amount for each one.

*NOTES*: 

- A detailed billing statement from the school for each semester being covered in the 

request must be provided. It must show what the school billed and who/what paid that bill.

- A letter from the child’s school on school letterhead stating the child’s enrollment in 

school status (full time or part time) and their expected graduation date is required for each 

semester being covered in the request. 

- If your student receives any scholarship or grant funds, these must be listed in block 

11e. If your student receives payments from a GI Bill, these must be listed in block 11i. Be sure 

to annotate what sort of GI Bill it is from (example: 9-11) and who’s GI Bill it is if applicable 

(student’s, yours, another parent, etc.). (If the GI Bill originally belongs to anyone other than 

the student and it was signed over to the student, please annotate who the original owner of 

the GI Bill is.) A copy of the GI bill showing what they paid to the school as well as any other 

additional funds paid to the student each month is also required.