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Military Dependent and Proof of Pregnancy Verification Statement

Service Members Rank and Full Name:
Command Information:
Command Contact Information:

I understand that by submitting this information, I am disclosing all information voluntarily and Operation
Showers of Appreciation (OSOA) is not obligated to assist my dependents based on my military status.

I certify that (Expectant Mothers Name):
is the Expectant Mother
Expectant Mother is my spouse
Expectant Mother is my fiance
the child is my dependent and I am not currently married to the Expectant
Mother

the child is my dependent and was adopted by my spouse and I

is the service member/my spouse/my fiance/expecting my dependent/expecting adopted dependent,

and is in fact pregnant at this time.
I understand that this document must be signed by my command representative and me prior to
being placed on any list for assistance by OSOA. I certify that all information disclosed above is true
to the best of my knowledge.
Falsificat