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

2. Family Care Plan
Letter of Instruction

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

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

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

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

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

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

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

10. 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

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