DD Form 93, Record of Emergency Data, January 2008

RECORD OF EMERGENCY DATA
PRIVACY ACT STATEMENT
AUTHORITY: 5 USC 552, 10 USC 655, 1475 to 1480 and 2771, 38 USC 1970, 44 USC 3101, and EO 9397 (SSN).
PRINCIPAL PURPOSES: This form is used by military personnel and Department of Defense civilian and contractor personnel, collectively referred to
as civilians, when applicable. For military personnel, it is used to designate beneficiaries for certain benefits in the event of the Service member's
death. It is also a guide for disposition of that member's pay and allowances if captured, missing or interned. It also shows names and addresses of
the person(s) the Service member desires to be notified in case of emergency or death. For civilian personnel, it is used to expedite the notification
process in the event of an emergency and/or the death of the member. The purpose of soliciting the SSN is to provide positive identification. All items
may not be applicable.
ROUTINE USES: None.
DISCLOSURE: Voluntary; however, failure to provide accurate personal identifier information and other solicited information will delay notification and
the processing of benefits to designated beneficiaries if applicable.
INSTRUCTIONS TO SERVICE MEMBER
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 (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.
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 DoD 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
1. NAME (Last, First, Middle Initial)
DOE, JOHN B.
2. SSN
123-45-6789
*(Complete BOTH front and back in PENCIL)
b. REPORTING UNIT CODE/DUTY STATION
3a. SERVICE/CIVILIAN CATEGORY
ARMY
NAVY
MARINE CORPS
AIR FORCE
DoD
4a. SPOUSE NAME (If applicable) (Last, First, Middle Initial)
CIVILIAN
CONTRACTOR
DET 085 BERKELEY, CA
b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
NONE
SINGLE
DIVORCED
WIDOWED
5. CHILDREN
a. NAME (Last, First, Middle Initial)
b. RELATIONSHIP
c. DATE OF BIRTH
(YYYYMMDD)
d. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
NONE
6a. FATHER NAME (Last, First, Middle Initial)
b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
DOE, BERT E.
123 SESAME ST.
FAIRFIELD, CA 94533
7a. MOTHER NAME (Last, First, Middle Initial)
DOE, MICHELLE K.
8a. DO NOT NOTIFY DUE TO ILL HEALTH
N/A
9a. DESIGNATED PERSON(S) (Military only)
N/A
(510) 643-9774
b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
SAME AS ITEM 6B
b. NOTIFY INSTEAD
N/A
b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
10. CONTRACTING AGENCY AND TELEPHONE NUMBER (Contractors only)
N/A
DD FORM 93, JAN 2008
PREVIOUS EDITION IS OBSOLETE.
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SECTION 2 - BENEFITS RELATED INFORMATION
11a. BENEFICIARY(IES) FOR DEATH GRATUITY
b. RELATIONSHIP c. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
d. PERCENTAGE
(Military only)
BERT E. DOE
FATHER
SAME AS ITEM 6B
50%
MICHELLE K. DOE
MOTHER
SAME AS ITEM 6B
50%
12a. BENEFICIARY(IES) FOR UNPAID PAY/ALLOWANCES
(Military only) NAME AND RELATIONSHIP
BERT E. DOE (FATHER)
b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
13a. PERSON AUTHORIZED TO DIRECT DISPOSITION (PADD)
(Military only) NAME AND RELATIONSHIP
b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER
LILY F. DOE (SISTER)
SAME AS ITEM 6B
c. PERCENTAGE
100
456 TRAVIS BLVD.
TRAVIS AFB, CA 94533
14. CONTINUATION/REMARKS
15. SIGNATURE OF SERVICE MEMBER/CIVILIAN (Include rank, rate, 16. SIGNATURE OF WITNESS (Include rank, rate, or grade
or grade if applicable)
DD FORM 93 (BACK), JAN 2008
as appropriate)
17. DATE SIGNED
(YYYYMMDD)
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INSTRUCTIONS FOR PREPARING DD FORM 93
(See appropriate Service Directives for supplemental instructions for completion of this form at other than MEPS)
All entries explained below are for electronic or typewriter
completion, except those specifically noted. If a computer
or typewriter is not available, print in black or blue-black ink
insuring a legible image on all copies. Include "Jr.," "Sr.,"
"III" or similar designation for each name, if applicable.
When an address is entered, include the appropriate ZIP
Code. If the member cannot provide a current address,
indicate "unknown" in the appropriate item. Addresses
shown as P.O. Box Numbers or RFD numbers should
indicate in Item 14, "Continuations/Remarks", a street
address or general guidance to reach the place of
residence. In addition, the notation "See Item 14" should be
included in the item pertaining to the particular next of kin or
when the space for a particular item is insufficient. If the
address for the person in the item has been shown in a
preceding item, it is unnecessary to repeat the address;
however, the name must be entered. Those items that are
considered not applicable to civilians will be left blank.
ITEM 1. Enter full last name, first name, and middle initial.
ITEM 2. Enter social security number (SSN).
ITEM 3a. Service. Military: Mark X in appropriate block.
Civilian: Mark two blocks as appropriate. Examples: an
Army civilian would mark Army and either Civilian or
Contractor; a DoD civilian, without affiliation to one of the
Military Services, would mark DoD and then either Civilian or
Contractor as appropriate.
ITEM 3b. Reporting Unit Code/Duty Station. See Service
Directives.
ITEM 4a. Spouse Name. Enter last name (if different from
Item 1), first name and middle initial on the line provided. If
single, divorced, or widowed, mark appropriate block.
ITEM 4b. Address and Telephone Number. Enter the
"actual" address and telephone number, not the mailing
address. Include civilian title or military rank and service if
applicable. If one of the blocks in 4a is marked, leave blank.
ITEM 5a-d. Children. Enter last name (only if different from
Item 1) first name and middle initial, relationship, and date of
birth of all children. If none, so state. Include illegitimate
children if acknowledged by member or paternity/maternity
has been judicially decreed. Relationship examples: son,
daughter, stepson or daughter, adopted son or daughter or
ward. Date of birth example: 19950704. For children not
living with the member's current spouse, include address
and name and relationship of person with whom residing in
item 5d.
ITEM 6a. Father Name. Last name, first name and middle
initial.
ITEM 6b. Address and Telephone Number of Father. If
unknown or deceased, so state. Include civilian title or
military rank and service if applicable. If other than natural
father is listed, indicate relationship.
DD FORM 93 (INSTRUCTIONS), JAN 2008
ITEM 7a. Mother Name. Last name, first name and middle
initial.
ITEM 7b. Address and Telephone Number of Mother. If
unknown or deceased, so state. Include civilian title or
military rank and service if applicable. If other than natural
mother is listed, indicate relationship.
ITEM 8. Persons Not to be Notified Due to Ill Health.
a. List relationship, e.g., "Mother," of person(s) listed in
Items 4, 5, 6, or 7 who are not to be notified of a casualty
due to ill health. If more than one child, specify, e.g.,
"daughter Susan." Otherwise, enter "None".
b. List relationship, e.g., "Father" or name and address of
person(s) to be notified in lieu of person(s) listed in item 8a.
If "None" is entered in Item 8a, leave blank.
ITEM 9a. This item will be used to record the name of the
person or persons, if any, other than the member's primary
next of kin or immediate family, to whom information on the
whereabouts and status of the member shall be provided if
the member is placed in a missing status. Reference 10
USC, Section 655. NOT APPLICABLE to civilians.
ITEM 9b. Address and telephone number of Designated
Person(s). NOT APPLICABLE to civilians.
ITEM 10. Contracting Agency and Telephone Number
(Contractors only). NOT APPLICABLE to military
personnel. Civilian contractors will provide the name of
their contracting agency and its telephone number.
Example: XYZ Electric, (703) 555-5689. The telephone
number should be to the company or corporation's
personnel or human resources office.
ITEM 11a. Beneficiary(ies) for Death Gratuity (Military
only). Enter first name(s), middle initial, and last name(s)
of the person(s) to receive death gratuity pay. A member
may designate one or more persons to receive all or a
portion of the death gratuity pay. The designation of a
person to receive a portion of the amount shall indicate the
percentage of the amount, to be specified only in 10 percent
increments, that the person may receive. If the member
does not wish to designate a beneficiary for the payment of
death gratuity, enter "None," or if the full amount is not
designated, the payment or balance will be paid as follows:
(1) To the surviving spouse of the person, if any;
(2) To any surviving children of the person and the
descendants of any deceased children by representation;
(3) To the surviving parents or the survivor of them;
(4) To the duly appointed executor or administrator of the
estate of the person;
(5) If there are none of the above, to other next of kin of the
person entitled under the laws of domicile of the person at
the time of the person's death.
The member should make specific designations, as it
expedites payment.
INSTRUCTIONS FOR PREPARING DD FORM 93
(Continued)
ITEM 11a. (Continued) Seek legal advice if naming a minor
child as a beneficiary. If a member has a spouse but
designates a person other than the spouse to receive all or a
portion of the death gratuity pay, the Service concerned is
required to provide notice of the designation to the spouse.
NOT APPLICABLE to civilians.
Item 11b. Relationship. NOT APPLICABLE to civilians.
ITEM 11c. Enter beneficiary(ies) full mailing address and
telephone number to include the ZIP Code. NOT
APPLICABLE to civilians.
ITEM 11d. Show the percentage to be paid to each person.
Enter 10%, 20%, 30%, up to 100% as appropriate. The sum
shares must equal 100 percent. If no percent is indicated and
more than one person is named, the money is paid in equal
shares to the persons named. NOT APPLICABLE to
civilians.
ITEM 12a. Beneficiary(ies) for Unpaid Pay/Allowance
(Military only). Enter first name(s), middle initial, last
name(s) and relationship of person to receive unpaid pay
and allowances at the time of death. The member may
indicate anyone to receive this payment. If the member
designated two or more beneficiaries, state the percentage
to be paid each in item 10c. If the member does not wish to
designate a beneficiary, enter "By Law." The member is
urged to designate a beneficiary for unpaid pay and
allowances as payment will be made to the person in order
of precedence by law (10 USC 2771) in the absence of a
designation. Seek legal advice if naming a minor child as
beneficiary. NOT APPLICABLE to civilians.
ITEM 12b. Enter beneficiary(ies) full mailing address and
telephone number to include the ZIP Code. NOT
APPLICABLE to civilians.
ITEM 12c. If the member designated two or more
beneficiaries, state the percentage to be paid each in this
section. The sum shares must equal 100 percent. NOT
APPLICABLE to civilians.
ITEM 13a. Enter the name and relationship of the Person
Authorized to Direct Disposition (PADD) of your remains
should you become a casualty. Only the following persons
may be named as a PADD: surviving spouse, blood relative
of legal age, or adoptive relatives of the decedent. If neither
of these three can be found, a person standing in loco
parentis may be named. NOT APPLICABLE to civilians.
DD FORM 93 (INSTRUCTIONS) (BACK), JAN 2008
ITEM 13b. Address and telephone number of PADD. NOT
APPLICABLE to civilians.
ITEM 14. Continuations/Remarks. Use this item for remarks
or continuation of other items, if necessary. Prefix entry with
the number of the item being continued; for example, 5/John
J./son/ 19851220/321 Pecan Drive, Schertz TX 78151. Also
use this item to list name, address, and relationship of other
persons the member desires to be notified. Other
dependents may also be listed. This block offers the
greatest amount of flexibility for the member to record other
important information not otherwise requested but
considered extremely useful in the casualty notification and
assistance process. Besides continuing information from
other blocks on this form, the member may desire to include
additional information such as: NOK language barriers,
location or existence of a Will, additional private insurance
information, other family member contact numbers, etc. If
additional space is required, attach a supplemental sheet of
standard bond paper with the information.
ITEM 15. Signature of Service Member/Civilian. Check and
verify all entries and sign all copies in ink as follows: First
name, middle initial, last name. Include rank, rate, or grade
if applicable. May be electronically signed (see DoD
Instruction 1300.18 for guidelines).
ITEM 16. Signature of Witness. Have a witness
(disinterested person) sign all copies in ink as follows: First
name, middle initial, last name. Include rank, rate, or grade
as appropriate. A witness signature is not required for
electronic versions of the DD Form 93 (see DoD Instruction
1300.18).
ITEM 17. Date the member or civilian signs the form. This
item is an ink entry and must be completed on all copies.