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. Reset Adobe 7.0 Professional 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) Reset 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.
© Copyright 2018 AnyForm