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Get DA 5840 2010

Notary Public My commission expires DA FORM 5840 JUN 2010 PREVIOUS EDITIONS ARE OBSOLETE. APD PE v1.00ES. CERTIFICATE OF ACCEPTANCE AS GUARDIAN OR ESCORT For use of this form see AR 600-20 the proponent agency is DCS G-1. PRIVACY ACT STATEMENT AUTHORITY 10 U*S*C. Section 3013 Secretary of the Army Army Regulation 600-20 Army Command Policy. PRINCIPAL PURPOSE Guardian s agreement to care for a soldier s child ren in his or her absence. ROUTINE USES None. DISCLOSURE Voluntary However failure to provide all the requested information could lead to rejection of a soldier s Family Care Plan* was provided an original DA Form 5841 I Power of Attorney or other legally sufficient authority naming me as guardian/escort for NAME s / AGE s OF FAMILY MEMBERS family members of NAME s I agree to accept responsibility for these family members. I have received all necessary documents required to provide financial medical educational quarters and subsistence support for these family members. I have been briefed on procedures for accessing military/civilian facilities services benefits and entitlements on behalf of these family members. TYPED OR PRINTED NAME OF GUARDIAN SIGNATURE ADDRESS Include ZIP Code DATE YYYY/MM/DD TELEPHONE NUMBER Include Area Code E-MAIL ADDRESS NOTARY STATE OF COUNTY OF Acknowledged before me this day of. CERTIFICATE OF ACCEPTANCE AS GUARDIAN OR ESCORT For use of this form see AR 600-20 the proponent agency is DCS G-1. PRIVACY ACT STATEMENT AUTHORITY 10 U*S*C. Section 3013 Secretary of the Army Army Regulation 600-20 Army Command Policy. PRIVACY ACT STATEMENT AUTHORITY 10 U*S*C. Section 3013 Secretary of the Army Army Regulation 600-20 Army Command Policy. PRINCIPAL PURPOSE Guardian s agreement to care for a soldier s child ren in his or her absence. ROUTINE USES None. PRINCIPAL PURPOSE Guardian s agreement to care for a soldier s child ren in his or her absence. ROUTINE USES None. DISCLOSURE Voluntary However failure to provide all the requested information could lead to rejection of a soldier s Family Care Plan* was provided an original DA Form 5841 I Power of Attorney or other legally sufficient authority naming me as guardian/escort for NAME s / AGE s OF FAMILY MEMBERS family members of NAME s I agree to accept responsibility for these family members. DISCLOSURE Voluntary However failure to provide all the requested information could lead to rejection of a soldier s Family Care Plan* was provided an original DA Form 5841 I Power of Attorney or other legally sufficient authority naming me as guardian/escort for NAME s / AGE s OF FAMILY MEMBERS family members of NAME s I agree to accept responsibility for these family members. I have received all necessary documents required to provide financial medical educational quarters and subsistence support for these family members. I have received all necessary documents required to provide financial medical educational quarters and subsistence support for these family members. I have been briefed on procedures for accessing military/civilian facilities services benefits and entitlements on behalf of these family members. .

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