ࡱ>  jabjbj *eed~$#FMd# # # # # # #$e%(.#ib"bb.#3#~~~b #~b#~~!|"пx ll""#0#~"/)l /)$"/)"du"~uuu.#.#xuuu#bbbb/)uuuuuuuuu : DEPENDENCY APPLICATION/RECORD OF EMERGENCY DATA 1. UNIT I.D. 66753SHIP OR STATION NROTC UNIT, JACKSONVILLE UNIVERSITY3. 4.5. NAME OF SPOUSE  FORMTEXT      6. DATE OF BIRTH OF SPOUSE  FORMTEXT      7. RELATIONSHIP  FORMTEXT      8. PLACE OF MARRIAGE (CITY & STATE OR COUNTRY)  FORMTEXT      DATE MARRIED  FORMTEXT      10.CITIZENSHIP OF SPOUSE  FORMTEXT      11. ADDRESS OF SPOUSE  FORMTEXT      12. DEP  FORMTEXT      13. NAME OF CHILD OR DEPENDENT 14. DATE OF BIRTH 15. RELATIONSHIP  FORMTEXT      16. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CLAIMANT) 17. DEP 18. NAME OR CHILD OR DEPENDENT  FORMTEXT      DATE OF BIRTH  FORMTEXT      20. RELATIONSHIP  FORMTEXT      21. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CLAIMANT)  FORMTEXT      22. DEP  FORMTEXT      23. NAME OR CHILD OR DEPENDENT  FORMTEXT      24. DATE OF BIRTH  FORMTEXT      25. RELATIONSHIP  FORMTEXT      26. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CLAIMANT)  FORMTEXT      27. DEP  FORMTEXT      28. NAME OR CHILD OR DEPENDENT  FORMTEXT      29. DATE OF BIRTH  FORMTEXT      30. RELATIONSHIP  FORMTEXT      31. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CLAIMANT)  FORMTEXT      32. DEP  33. NAME OF FATHER 34. ADDRESS OF FATHER(SEE SPECIAL INSTRUCTIONS BEFORE COMPLETING BLOCK 35) 35. DEP NO36. NAME OF MOTHER 37. ADDRESS OF MOTHER(SEE SPECIAL INSTRUCTIONS BEFORE 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      46. PLACE (CITY & STATE OR COUNTRY)  FORMTEXT      47. OTHER 48. 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RELATIONSHIP 63. % 10064. LIFE INSRUANCE DATA (NAME OF CO) (DO NOT INCLUDE SGLI)  FORMTEXT      65 ADDRESS  FORMTEXT      POLICY NUMBER  FORMTEXT       67. RELGION 68.69.70. RANK/RATE MIDNPAGE 1OF PAGES 173. NAME OF DESIGNATOR (LAST, FIRST, MIDDLE) 74. SSN 75. USN 76. USNR  FORMCHECKBOX   FORMCHECKBOX  PART II NAVPERS 1070/602(5C)(Rev.7.72)S/N0106-018-6022 BUREAU OF NAVAL PERSONNEL *U.S. GOVERNMENT PRINTING OFFICE: 1986-491-648/T-40024 NAVPERS 1070/602 (Rev. 7-72) (PART II) (BACK) 77. LOCATION OF WILL OR OTHER VALUABLE PAPERS 78. REMARKS Is beneficiary designation of S.G.L.I. on file?  FORMCHECKBOX  YES  FORMCHECKBOX  NODATE (IF YES)  NOTE: THIS FORM DOES NOT DESIGNATE OR CHANGE BENEFICIARIES OF GOV T LIFE INSURANCE. 79. SIGNATURE OF DESIGNATOR 80. SIGNATURE OF APPROVING OFFICER, TITLE, AND DATE  FORMTEXT       CERTIFICATION OF DESIGNATOR I have reviewed the data entered on this form and certify that it is correct. Execute a new NAVPERS 1070/602 if data is not correct. 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