Family Care PlanRank/Name: CPT Cooper, DavidUnit/Section: Ops Co, DHHBCurrent Status______________________

KE. 25 600-20e Pregnancy and Family Care counselingPA: A0001bAHRC

Event is upon transfer or separation of individual. Keep in CFA until event occurs; destroy 90 after the event. If individual is transferred onpost, send to gaining organization.

Family Care Plan Checklist

1. Letter of Instruction Yes___ No___ Date________

2. DA Form 5304 - Family Care Plan Checklist Yes___ No___ Date________

3. DA Form 5305 - Family Care Plan Yes___ No___ Date________

4. DA Form 5840 – Long Term Certificate of Acceptance Yes___ No___ Date________a. notarized Yes___ No___

5. DA Form 5841 – Long Term Power of Attorney Yes___ No___ Date________ a. notarized Yes___ No___

6. DA Form 5840 – Short Term Certificate of Acceptance Yes___ No___ Date________ a. notarized Yes___ No___

7. DA Form 5841 – Short Term Power of Attorney Yes___ No___ Date________ a. notarized Yes___ No___

8. DA Form 4856 – Counseling by Commander Yes___ No___ Date________

9. DD Form 1172-2 – DEERS Enrollment form Yes___ No___ Date________

10. DD Form 2558 - Allotment form Yes___ No___ Date________

Certified by________________________________________ Date______________Recertified by______________________________________ Date_______________Recertified by______________________________________ Date_______________

Family Care PlanLetter of Instruction

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

(3 pages)

EXAM

PLE

Family Care Plan(DA Form 5305, Jun 2010)

(2 pages)

EXAM

PLE

Long Term Provider Certificate of Acceptance(DA Form 5840, Jun 2010)

(MUST BE NOTARIZED)

EXAM

PLE

Long Term Provider Power of Attorney(DA Form 5841, Jun 2009)

(2 pages)(MUST BE NOTARIZED)

EXAM

PLE

Short Term Provider Certificate of Acceptance(DA Form 5840, Jun 2010)

(MUST BE NOTARIZED)

EXAM

PLE

Short Term Provider Power of Attorney(DA Form 5841, Jun 2009)

(2 pages)(MUST BE NOTARIZED)

EXAM

PLE

Developmental Counseling Form(DA Form 4856, Aug 2010)

EXAM

PLE

Application for Uniformed Services Identification CardDEERS Enrollment

(DD Form 1172-2, Apr 2012)(Must have the form signed from DEERS for each dependant, NOT a copy of the dependant’s ID Card)

EXAM

PLE

Authorization to Start, Stop or Change an Allotment(DD Form 2558, Aug 2002)

EXAM

PLE

NO DATE

NO DATE