Family Care Plan Rank/Name ______________________________________ Platoon/Section ________________ Current Status __________________

Family Care Plan Checklist 1. Letter of Instruction Yes___ No___ Date__________ 2. DA Form 5304 – FCP Counseling Checklist Yes ___ No ___ Date _________ 3. DA Form 5305 – Family Care Plan Yes ___ No ___ Date _________ 4. DA Form 5841 – Long Term provider POA Yes ___ No ___ Date _________ a. Notarized Yes ___ No ___ 5. DA Form 5840 – Long Term Cert of Acceptance Yes ___ No ___ Date _________ a. Notarized Yes ___ No ___ 6. DA Form 5841 – Short Term provider POA Yes ___ No ___ Date _________ a. Notarized Yes ___ No ___ 7. DA Form 5840 – Short Term Cert of Acceptance Yes ___ No ___ Date _________ a. Notarized Yes ___ No ___ 8. DA Form 4856 – Developmental Counseling by CDR Yes ___ No ___ Date _________ 9. DD Form 1172 – DEERS Enrollment form Yes ___ No ___ Date _________ 10. DD Form 2558 – Allotment form Yes ___ No ___ Date _________ Certified by ____________________________________________ Date ______________ Recertified by __________________________________________ Date ______________

Family Care Plan Letter of Instruction

Family Care Plan Counseling Checklist (DA Form 5304, Dec 2005) (3 Pages)

Family Care Plan (DA Form 5305, Dec 2005) (2 Pages)

Long Term Provider Power of Attorney (DA Form 5841, Dec 2005) (2 Pages) (Must be notarized)

Long Term Certificate of Acceptance (DA Form 5840, Dec 2005) (Must be notarized)

Short Term Provider Power of Attorney (DA Form 5841, Dec 2005) (2 Pages) (Must be notarized)

Short Term Certificate of Acceptance (DA Form 5840, Dec 2005) (Must be notarized)

Developmental Counseling Form (DA Form 4856, Mar 2006) (Signed by the Commander) (2 Pages)

ID Card DEERS Enrollment (DD Form 1172, Sep 2005) (Must have the form signed from DEERS, not a copy of the dependant’s ID Card)

Authorization to Start an Allotment (DD Form 2558, Sep 2002) No date

AR Army Command Policy (18 March 2008) Pages 37-41