Evacuation Information Verification Sheet

Name_______________________________      SS# _________-_______-___________   Grade ______

Relationship to Sponsor _________________       Date of Birth/Marriage. ____/_____/____

Sponsor’s Name ______________________      SS# _________-_______-___________   Grade_______

Safe Haven Address    _______________________________            Phone  _________________________

City, State, Zip        __________________________________          E-Mail_________________________

Did you drive your P.O.V. to your Safe haven Location?      Yes_______       No_______

Did you retain your P.O.V at your Safe haven Location?       Yes_______       No_______

Did your sponsor claim transportation (Mileage) to Safe Haven location for this POV?   Yes ___    No  ___

If no, please provide License Pate # for this POV claimed ________________
If Sponsor claimed any transportation (Mileage), please provide license plate # for POV ______________

List Name and Date of Birth of Dependents who evacuated with you:

1._____________________________ Date of Birth/Marriage. _____________   Relationship _____________
2._____________________________ Date of Birth/Marriage. _____________   Relationship _____________  
3._____________________________ Date of Birth/Marriage. _____________   Relationship _____________
4._____________________________ Date of Birth/Marriage. _____________   Relationship _______________   5._____________________________ Date of Birth/Marriage. _____________   Relationship _____________
6._____________________________ Date of Birth/Marriage. _____________   Relationship _____________

                                                    
                                             Bank Information For Direct Deposit

          Bank Routing Number    _________________________________________

          Bank Account Number   _________________________________________

          Checking Account   _____________       Savings Account ______________	

                          IAW DoDFMR 0703, identification and validation of dependency has been verified for all evacuees on this form.

Signature: ________________________________      Date: _______________________

Signature: ________________________________      Date: _______________________

*Dual signature is only required if any of the evacuees does not have an acceptable form of identification per 0703