Fillable Combat Badge Da Form 4187 - New Ncoer printable pdf download

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PERSONNEL ACTION

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

AUTHORITY:

PRINCIPAL PURPOSE:

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

ROUTINE USES:

apply to this system.

Voluntary; however failure to provide Social Security Number may result in a delay or error in processing the

DISCLOSURE:

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

Department 480

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.

E-5/11B2O

123-45-6789

SECTION II - DUTY STATUS CHANGE (AR 600-8-6)

7. The above Soldier's duty status is changed from

effective

hours,

SECTION III - REQUEST FOR PERSONNEL ACTION

8. I request the following action: (Check as appropriate)

(Enl only)

Service School

Special Forces Training/Assignment

Identification Card

(Enl only)

ROTC or Reserve Component Duty

On-the-Job Training

Identification Tags

Volunteering For Oversea Service

Retesting in Army Personnel Tests

Separate Rations

Ranger Training

Reassignment Married Army Couples

Leave - Excess/Advance/Outside CONUS

Reassignment Extreme Family Problems

Reclassification

Change of Name/SSN/DOB

Other (Specify)

(Enl only)

Officer Candidate School

Exchange Reassignment

Award of the Combat XXXXX Badge

Airborne Training

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:

b. Location:

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.

Enclosures:

1-DA Form 4187

2-DD Form 214

3-Deployment/Mobilization Orders

4-Narrative

5-ORB/ERB/DA Form 2-1

6-Eyewitness Statements (Minimum 2, other than the recommended recipient)

7-Incident Report

8-Commander's Recommendation

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

RECOMMEND APPROVAL

RECOMMEND DISAPPROVAL

IS APPROVED

IS DISAPPROVED

12. COMMANDER/AUTHORIZED REPRESENTATIVE

13. SIGNATURE

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

Combat Badge Da Form 4187 - New Ncoer

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