Family Care Plan

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 5304 - Family Care Plan Checklist
  Yes___ No___ Date________
• DA Form 5305 - 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___
• 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________

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