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1 . U N I T I . D .
6 6 7 5 3 S H I P O R S T A T I O N
N R O T C U N I T , J A C K S O N V I L L E U N I V E R S I T Y 3 . 4 . 5 . N A M E O F S P O U S E
F O R M T E X T 6 . D A T E O F B I R T H O F S P O U S E
F O R M T E X T 7 . R E L A T I O N S H I P
F O R M T E X T 8 . P L A C E O F M A R R I A G E ( C I T Y & S T A T E O R C O U N T R Y )
F O R M T E X T D A T E M A R R I E D
F O R M T E X T 1 0 . C I T I Z E N S H I P O F S P O U S E
F O R M T E X T 1 1 . A D D R E S S O F S P O U S E
F O R M T E X T 1 2 . D E P
F O R M T E X T 1 3 . N A M E O F C H I L D O R D E P E N D E N T
1 4 . D A T E O F B I R T H
1 5 . R E L A T I O N S H I P
F O R M T E X T 1 6 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
1 7 . D E P
1 8 . N A M E O R C H I L D O R D E P E N D E N T
F O R M T E X T D A T E O F B I R T H
F O R M T E X T 2 0 . R E L A T I O N S H I P
F O R M T E X T 2 1 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
F O R M T E X T 2 2 . D E P
F O R M T E X T 2 3 . N A M E O R C H I L D O R D E P E N D E N T
F O R M T E X T 2 4 . D A T E O F B I R T H
F O R M T E X T 2 5 . R E L A T I O N S H I P
F O R M T E X T 2 6 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
F O R M T E X T 2 7 . D E P
F O R M T E X T 2 8 . N A M E O R C H I L D O R D E P E N D E N T
F O R M T E X T 2 9 . D A T E O F B I R T H
F O R M T E X T 3 0 . R E L A T I O N S H I P
F O R M T E X T 3 1 . A D D R E S S ( I N C L U D E N A M E O F C U S T O D I A N I F O T H E R T H A N C L A I M A N T )
F O R M T E X T 3 2 . D E P
3 3 . N A M E O F F A T H E R
3 4 . A D D R E S S O F F A T H E R ( S E E S P E C I A L I N S T R U C T I O N S B E F O R E C O M P L E T I N G B L O C K 3 5 )
3 5 . D E P
N O 3 6 . N A M E O F M O T H E R
3 7 . A D D R E S S O F M O T H E R ( S E E S P E C I A L I N S T R U C T I O N S B E F O R E COMPLETING BLOCK 38)
38. DEP
NO39. WERE YOU PREVIOUSLY
MARRIED? FORMCHECKBOX YES FORMCHECKBOX NO40. PRIOR MARRIAGE DISSOLVED BY
FORMCHECKBOX DEATH FORMCHECKBOX ANNULMENT FORMCHECKBOX DIVORCE41. DATE
42. PLACE (CITY & STATE OR COUNTRY)
43. WAS SPOUSE PREVIOUSLY
MARRIED? FORMCHECKBOX YES FORMCHECKBOX NO44. PRIOR MARRIAGE DISSOLVED BY
FORMCHECKBOX DEATH FORMCHECKBOX ANNULMENT FORMCHECKBOX DIVORCE45. DATE
FORMTEXT 4 6 . P L A C E ( C I T Y & S T A T E O R C O U N T R Y )
F O R M T E X T 4 7 . O T H E R
4 8 . A D D R E S S
F O R M T E X T 4 9 . R E L A T I O N S H I P
F O R M T E X T 5 0 . N E X T O F K I N O F S P O U S E ( N O T H U S B A N D , W I F E O R M I N O R C H I L D ) F O R M T E X T 5 1 . A D D R E S S
F O R M T E X T 5 2 . R E L A T I O N S H I P
F O R M T E X T 5 3 . B E N E F I C I A R Y ( S ) F O R U N P A I D P A Y A N D A L L O W A N C E S
5 4 . A D D R E S S
5 5 . R E L A T I O N S H I P
5 6 . %
1 0 0 5 7 . P E R S O N T O R E C E I V E A L L O T M E N T I F I N A M I S S I N G S T A T U S . S U B J E C T T O S E C N A V D E T E R M I N A T I O N
5 8 . A D D R E S S
5 9 . %
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6 1 . A D D R E S S
6 2 . R E L A T I O N S H I P
6 3 . %
1 0 0 6 4 . L I F E I N S R U A N C E D A T A ( N A M E O F C O ) ( D O N O T I N C L U D E S G L I )
F O R M T E X T 6 5 A D D R E S S
F O R M T E X T P O L I C Y N U M B E R
F O R M T E X T
6 7 . R E L G I O N
6 8 . 6 9 . 7 0 . R A N K / R A T E
M I D N P A G E
1 O F P A G E S
1 7 3 . N A M E O F D E S I G N A T O R ( L A S T , F I R S T , M I D D L E )
7 4 . S S N
7 5 . U S N 7 6 . U S N R
F O R M C H E C K B O X F O R M C H E C K B O X
P A R T I I
N A V P E R S 1 0 7 0 / 6 0 2 ( 5 C ) ( R e v . 7 . 7 2 ) S / N 0 1 0 6 - 0 1 8 - 6 0 2 2 B U R E A U O F N A V A L P E R S O N N E L
* U . S . G O V E R N M E N T P R I N T I N G O F F I C E : 1 9 8 6 - 4 9 1 - 6 4 8 / T - 4 0 0 2 4
N A V P E R S 1 0 7 0 / 6 0 2 ( R e v . 7 - 7 2 ) ( P A R T I I ) ( B A C K )
7 7 . L O C A T I O N O F W I L L O R O T H E R V A L U A B L E P A P E R S
7 8 . R E M A R K S
I s b e n e f i c i a r y d e s i g n a t i o n o f S . G . L . I . o n f i l e ? F O R M C H E C K B O X Y E S F O R M C H E C K B O X N O D A T E ( I F Y E S )
N O T E : T H I S F O R M D O E S N O T D E S I G N A T E O R C H A N G E B E N E F I C I A R I E S O F G O V T L I F E I N S U R A N C E .
7 9 . S I G N A T U R E O F D E S I G N A T O R
8 0 . S I G N A T U R E O F A P P R O V I N G O F F I C E R , T I T L E , A N D D A T E
F O R M T E X T
C E R T I F I C A T I O N O F D E S I G N A T O R
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E x e c u t e a n e w N A V P E R S 1 0 7 0 / 6 0 2 i f d a t a i s n o t c o r r e c t .
D A T E S I G N A T U R E O F D E S I G N A T O R D A T E S I G N A T U R E O F D E S I G N A T O R
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