Da Form 5840 - Certificate Of Acceptance As Guardian Or Escort

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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.
None.
ROUTINE USES:
Voluntary; However, failure to provide all the requested information could lead to rejection of a soldier's
DISCLOSURE:
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
ADDRESS (Include ZIP Code)
SIGNATURE
DATE (YYYY/MM/DD)
TELEPHONE NUMBER (Include Area Code)
E-MAIL ADDRESS
NOTARY:
STATE OF
COUNTY OF
Acknowledged before me this
day of
,
.
(Notary Public)
My commission expires:
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00ES
DA FORM 5840, JUN 2010

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