Da Form 5305 - Family Care Plan Page 2
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1
2B.
I (We) have designated the following individual(s) as principal long-term guardian(s) for my(our) family member(s). The designated guardian(s)
reside in the continental United States or United States territories.
COMPLETE ADDRESS (Including Street, Apartment Number,
1.
TYPED OR PRINTED NAME
2a.
P.O. Box Number, Rural Route Number, City, State, and ZIP + 4
where applicable)
3.
TELEPHONE NUMBER (Include Area Code)
2b.
E-MAIL ADDRESS
C.
I (We) have designated the following individual(s) as escort for my(our) family member(s) if evacuation from OCONUS becomes necessary (applies
only to persons assigned OCONUS):
COMPLETE ADDRESS (Including Street, Apartment Number,
1.
TYPED OR PRINTED NAME
2a.
P.O. Box Number, Rural Route Number, City, State, and ZIP + 4
where applicable)
3.
TELEPHONE NUMBER (Include Area Code)
2b.
E-MAIL ADDRESS
PART III - DUAL MILITARY COUPLES ONLY
MILITARY SPOUSE AND COMMANDER CERTIFICATION
Spouse: We have made arrangements and will maintain arrangements for the care of our family member(s) in all circumstances required by our
A .
commitment to the military and our family.
1.
SIGNATURE OF SPOUSE
2.
DATE (YYYY/MM/DD)
3.
TYPED OR PRINTED NAME OF SPOUSE
a. INIT.
b. INIT.
c. INIT.
d. INIT.
e. INIT.
DATE
DATE
DATE
DATE
DATE
4.
Recertification
B.
Commander: I have counseled the military spouse assigned to my unit, reviewed the Family Care Plan, and I am satisfied that the members have
made adequate family care arrangements.
1.
SIGNATURE OF COMMANDER
2.
DATE
3.
UNIT ADDRESS
4.
TYPED OR PRINTED NAME OF COMMANDER
a. INIT.
b. INIT.
c. INIT.
d. INIT.
e. INIT.
DATE
DATE
DATE
DATE
DATE
5.
Recertification
PART IV - SOLDIER AND COMMANDER CERTIFICATION
Soldier: I (We) have made arrangements and will maintain arrangements for the care of my(our) family member(s) in all circumstances required by
A .
my(our) commitment to the military and my(our) family.
1.
SIGNATURE OF SOLDIER
2.
DATE (YYYY/MM/DD)
3.
TYPED OR PRINTED NAME OF SOLDIER
a. INIT.
b. INIT.
c. INIT.
d. INIT.
e. INIT.
DATE
DATE
DATE
DATE
DATE
4.
Recertification
B.
Commander: I have reviewed the Family Care Plan, and I am satisfied that the members have made adequate family care arrangements that will
allow for a full range of military duties and for worldwide availability as defined here.
1.
SIGNATURE OF COMMANDER
2.
DATE
3.
UNIT ADDRESS
4.
TYPED OR PRINTED NAME OF COMMANDER
a. INIT.
b. INIT.
c. INIT.
d. INIT.
e. INIT.
DATE
DATE
DATE
DATE
DATE
5.
Recertification
APD LC v1.00ES
REVERSE OF DA FORM 5305, JUN 2010
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