RECORD OF EMERGENCY DATA

AUTH
PRINCIPAL PURPOS!
as civilians, when appli fable, For

the person(s) the
process in the event of an emergency and/or the death of the member.
not be applicable.
TINE U: : None.

the processing of benefits to designated beneficiaries if applical

PRIVACY ACT STATEMENT

IORITY: 5 USC oa RAS USC 655, 1475 to 1480 and 2771, 38 USC 1970, 44 USC 3101, and EO 9397 (SSN).
This form is used by military personnel and Department of Defense civilian and contractor Lelegey sq collectively referred to
Personnel, it is used to designate beneficiaries for certain benefits in the event of
death. Itis alsoa iss for disposition of that member's pay and allowances if captured, missing or interned. It also shows names and addresses of
member desires to be notified in case of merency or death. For civilian
he purpose of soliciting the

RO!
DISCLOSURE: Voluntary; however, failure to provide Spoor ol a identifier information and other solicited information will delay notification and

the Service member's

sonnel, it is used to expedite the notification
Nis to provide positive identification. All items

INSTRUCTIONS TO SERVICE MEMBER

This extremely important form is to be used by you to show the names and
addresses of your spouse, children, parents, and any other person(s) you
would like notfied if you become a casualty (other family members or fiance),
and, to designate beneficiaries for certain benefits if you die. IT IS YOUR
RESPONSIBILITY to keep your Record of Emergency Data up to date to show
your desires as to beneficiaries to receive certain death payments, and to
show changes in your family or other personnel listed, for example, as a result
of marriage, civil court action, death, or address change.

INSTRUCTIONS TO CIVILIANS

This extremely important form is to be used by you to show the
names and addresses of your spouse, children, parents, and any
other person(s) you would like notified if you become a casualty
Not every item on this form is applicable to you, This form is used
by the Department of Defense (DoD) to expedite notification in
the case of emergencies or death. It does not have a legal impact
on other forms you may have completed with the DeD or your

employer.

IMPORTANT: This form is divided into two sections: Section 1 - Emergency Contact Information and Section 2 - Benefits Related
Information. READ THE INSTRUCTIONS ON PAGES 3 AND 4 BEFORE COMPLETING THIS FORM.

SECTION 1 - EMERGENCY CONTACT INFORMATION

4. NAME (Last, First, Middle Initia)

2 SSN

‘Sa. SERVICEICIVILIAN CATEGORY

[Janu [J mavy []mariecores [TJarrorce [“] 000 [_]cnmuan [contractor

Bb. REPORTING UNIT CODE/DUTY STATION
DoD/DIA

4a. SPOUSE NAME (if apptcable) (Last, First, Middle Initial)

[J swnote [_Jowvorceo [_] mooweo

b, ADDRESS (Include 2iP Code) AND TELEPHONE NUMBER

‘5. CHILDREN

a. NAME (Last First, Middle initia) dite

. DATE OF BIRTH
(yYyYMMoD)

d. ADDRESS (include ZiP Code) AND TELEPHONE NUMBER

Ga. FATHER NAME (Last, First, Middle initial)

Bb, ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

Ta. MOTHER NAME (Last, First, Middle Inital)

1, ADDRESS (include ZIP Code) AND TELEPHONE NUMBER

DO NOT NOTIFY DUE TO ILL HEALTH b. NOTIFY INSTEAD

| 9a. DESIGNATED PERSON(S) (Miltary only) ’b, ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
‘Do Not Complete Do Not Complete

40. CONTRACTING AGENCY AND TELEPHONE NUMBER (Contractors only)
Do Not Complete

DD FORM 93, JAN 2008

PREVIOUS EDITION IS OBSOLETE.

‘Acate 70 Professions


SECTION 2 - BENEFITS RELATED INFORMATION

(Miftary only)

Do Not
Do Not Complete Complete

‘11a. BENEFICIARY(IES) FOR DEATH GRATUITY | b. RELATIONSHIP

Do Not Complete

¢. ADDRESS (Include Z/P Code) AND TELEPHONE NUMBER =| d. PERCENTAGE

Do Not
Complete

12a. BENEFICIARY(IES) FOR UNPAID PAYIALLOWANGES
(Niktary only) NAME AND RELATIONSHIP

Dp Not Complete

Do Not Complete

b. ADDRESS (Include 2(P Code) AND TELEPHONE NUMBER | c, PERCENTAGE

13a. PERSON AUTHORIZED TO DIRECT DISPOSITION (PADD)
(Miltary only) NAME AND RELATIONSHIP

Do Not Complete

Do Not Complete

'B. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

14, CONTINUATION/REMARKS

Do Not Complete

15. SIGNATURE OF SERVICE MEMBERICIVILIAN (inciudo rank, rate,
‘oF grade if eppiicable)

16. SIGNATURE OF WITNESS (Include rank, rate, or grade
«as appropriate)

17. DATE SIGNED
(YYYYMMOD)

DD FORM 93 (BACK), JAN 2008