For use of this form, see PAM 600-8; the proponent agency is DCS, G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, USC, Section 3013, E.O. 9397 (SSN), as amended
To request or record personnel actions for or by Soldiers in accordance with DA PAM 600-8.
The DoD Blanket Routine Uses that appear at the beginning of the Army's compilation of systems of records may
apply to this system.
Voluntary; however failure to provide Social Security Number may result in a delay or error in processing the
request for personnel action.
3. FROM (Include ZIP Code)
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
Soldier's Higher Headquarters
U.S. Army Human Resources Command
Soldier's Current Unit of Assignment
Complete mailing address
1600 Spearhead Division Avenue,
Include complete mailing address
Fort Knox, KY 40122-5408
SECTION I - PERSONAL IDENTIFICATION
4. NAME (Last, First, MI)
5. GRADE OR RANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
Doe, John A.
SECTION II - DUTY STATUS CHANGE (AR 600-8-6)
7. The above Soldier's duty status is changed from
SECTION III - REQUEST FOR PERSONNEL ACTION
8. I request the following action: (Check as appropriate)
Special Forces Training/Assignment
ROTC or Reserve Component Duty
Volunteering For Oversea Service
Retesting in Army Personnel Tests
Reassignment Married Army Couples
Leave - Excess/Advance/Outside CONUS
Reassignment Extreme Family Problems
Change of Name/SSN/DOB
Officer Candidate School
Award of the Combat XXXXX Badge
Asgmt of Pers with Exceptional Family Members
9. SIGNATURE OF SOLDIER (When required)
10. DATE (YYYYMMDD)
SECTION IV - REMARKS (Applies to Sections II, III, and V) (Continue on separate sheet)
1. Request that SFC _______________ be awarded the Combat _______ Badge for personally being engaged by the enemy.
2. The following information is provided:
a. Date of Engagement:
c. Soldier (example) was within XX meter(s) from impact of (circle one) Small Arms Fire, Sniper Fire, IED, VBIED, or Artillery.
Soldier performed medical duties while under fire.
3. Situation: While providing security at the New Baghdad Police Station during the Iraqi's Free Elections, SFC ________ came
under direct fire. Additional information is provided in the narrative and eyewitness statements.
1-DA Form 4187
2-DD Form 214
5-ORB/ERB/DA Form 2-1
6-Eyewitness Statements (Minimum 2, other than the recommended recipient)
SECTION V - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that the request for personnel action (Section III) contained herein -
HAS BEEN VERIFIED
12. COMMANDER/AUTHORIZED REPRESENTATIVE
14. DATE (YYYYMMDD)
SUPERSEDES DA FORM 4187, JAN 2000
DA FORM 4187, MAY 2014
Page 1 of 2
AND REPLACES DA FORM 4187-1-R, APR 1995
APD LC v1.03ES