Da Form 5305 - Family Care Plan printable pdf download

FAMILY CARE PLAN

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 and E.O. 9397 (SSN)

PRINCIPAL PURPOSE:

To emphasize to soldiers the significance of their responsibilities to the military service and their family members while

performing required military duties.

ROUTINE USES:

None

DISCLOSURE:

Mandatory; Failure to maintain a Family Care Plan could subject the soldier to separation, administrative action, or

disciplinary action under the UCMJ.

PART I - SOLDIER'S FAMILY CARE

INITIALS

I was counseled on

(date) , and fully understand the policy on family member

care responsibilities. I understand that I must arrange for care of my family members, remain available for deployment and

training, and report for duty as required without interference of responsibility for family members. I assume responsibility for all

obligations for such things as child care, food, adequate housing, transportation, and emergency needs of my family members

regardless of age.

I have made and will maintain arrangements for the care of my family members during all the following:

Duty

Temporary Duty

11.

Deployment

Exercises/field duty

Unit Training Assembly

12.

Other Military Duty

Permanent Change of Station

Active Duty Training

13.

Emergencies

Alerts

Unaccompanied Tours

14.

Leave/non-duty Time

Annual Training

10.

Mobilization

I understand the importance of ensuring the proper care for my family members, and ensuring my own readiness and

deployability as well. I further understand that in light of the critical nature of both these requirements:

Failure to make and maintain adequate family member care arrangements in accordance with the Army's policy is grounds

for disciplinary action or separation.

Nonavailability for worldwide assignment and/or unit deployment may lead to my separation from the Army.

If arrangements for the care of my family members fail to work, I am not automatically excused from prescribed duties,

unit deployment, or reassignment.

If I fail to maintain a Family Care Plan or provide false information regarding my plan, I am subject to separation,

administrative action, or disciplinary action under UCMJ.

I must maintain an up-to-date Family Care Plan and revise my Plan when circumstances change. I understand that Family

Care Plans may be tested at the discretion of the commander.

I will receive no special consideration in duty assignments or duty stations based on my responsibilities for my

family members unless enrolled in the Exceptional Family Member Program (EFMP) in accordance with AR 600-75.

I have made all necessary arrangements

(legal, educational, financial, religious, special, etc.)

to ensure a smooth, rapid

turnover of family member care responsibilities in case this plan is implemented.

I have arranged for necessary travel required to transfer my family members to a designated person. If my principal designee is

not in the local area, I have arranged with a nonmilitary person in the local area to assume temporary guardianship of my family

members until they are transferred to my principal care designee, or that designee arrives to assume responsibility for their care.

A copy of DA Form 5841 (Power of Attorney) or equivalent documents and a copy of DA Form 5840 (Certificate

of Acceptance as Guardian) for each escort or guardian whether temporary or long-term is attached to this plan.

The following additional required documents are completed, included in this plan, and will be put into effect as part of my Family

Care Plan.

1. DD Form 1172 (Application for Uniformed Services Identification Card) for each family member whether they have a

currently valid ID card or not.

2. DD Form 2558 (Authorization to Start, Stop or Change an Allotment for Active Duty or Retired Personnel) or other proof of

financial support for expenses incurred by guardian and family members.

3. Copies of Letters of Instruction (which have been forwarded to designated escorts or guardians along with powers of

attorney and other pertinent documents), outlining all special instructions concerning the care of my family members have also

been included in my Family Care Plan.

I have thoroughly briefed escorts and guardians on the full extent of their responsibilities and on procedures for gaining access to

military/civilian facilities, services, entitlements and benefits on behalf of my family members.

I am confident that my Family Care Plan is workable, and to the best of my knowledge, the guardian(s) and escort(s) I have

designated will be both willing and able to carry out the responsibilities of caring for my family members.

PART II - DESIGNATION OF GUARDIANS/ESCORTS

I (We) have designated the following temporary guardian to care for my (our) family member (s) until responsibility is transferred to escort or

principal (long-term) guardian.

TYPED OR PRINTED NAME

2a.

COMPLETE ADDRESS (Including Street, Apartment Number,

P.O. Box Number, Rural Route Number, City, State, and ZIP + 4

where applicable)

TELEPHONE NUMBER (Include Area Code)

2b. E- MAIL ADDRESS

DA FORM 5305, DEC 2005

DA FORM 5305-R, APR 1999 IS OBSOLETE

APD V1.00

Da Form 5305 - Family Care Plan

Related Articles

Related forms

Related Categories