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

2. Family Care Plan Checklist
Letter of Instruction Yes___ No___ Date________
DA Form Family Care Plan Checklist Yes___ No___ Date________
DA Form Family Care Plan Yes___ No___ Date________
DA Form 5840 – Long Term Certificate of Acceptance Yes___ No___ Date________
notarized Yes___ No___
DA Form 5841 – Long Term Power of Attorney Yes___ No___ Date________
a. notarized Yes___ No___
DA Form 5840 – Short Term Certificate of Acceptance Yes___ No___ Date________
a. notarized Yes___ No___
DA Form 5841 – Short Term Power of Attorney Yes___ No___ Date________
DA Form 4856 – Counseling by Commander Yes___ No___ Date________
DD Form DEERS Enrollment form Yes___ No___ Date________
DD Form Allotment form Yes___ No___ Date________
Certified by________________________________________ Date______________
Recertified by______________________________________ Date_______________

3. Family Care Plan
Letter of Instruction

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

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

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

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

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

11. 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

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