Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________

Family Care Plan Letter of Instruction

Family Care Plan Counseling Checklist (DA Form 5304, Jun 2010) (3 pages) EXAMPLE

Family Care Plan (DA Form 5305, Jun 2010) (2 pages) EXAMPLE

Long Term Provider Certificate of Acceptance (DA Form 5840, Jun 2010) (MUST BE NOTARIZED) EXAMPLE

Short Term Provider Certificate of Acceptance (DA Form 5840, Jun 2010) (MUST BE NOTARIZED) EXAMPLE

Long Term Provider Power of Attorney (DA Form 5841, Jun 2010) (2 pages) (MUST BE NOTARIZED) EXAMPLE

Short Term Provider Power of Attorney (DA Form 5841, Jun 2010) (2 pages) (MUST BE NOTARIZED) EXAMPLE

Developmental Counseling Form (DA Form 4856, Aug 2010) EXAMPLE

Application for Uniformed Services Identification Card DEERS Enrollment (DD Form 1172, Aug 2002) (Must have the form signed from DEERS, not a copy of the dependant’s ID Card) EXAMPLE

Authorization to Start, Stop or Change an Allotment (DD Form 2558, Aug 2002) EXAMPLE NO DATE NO DATE