Department Of The Navy Family Care Certificate

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FILLABLE FORM
DEPARTMENT OF THE NAVY
FAMILY CARE CERTIFICATE
SUPPORTING DIRECTIVE OPNAVINST 1740.4C
PRIVACY ACT ADVISEMENT
AUTHORITY: 44 U.S.C. Section 3101; 5 U.S.C. Section 301; 10 U.S.C. Sections 133 and 5031; E.O. 9397; and OPNAVINST 1740.4B
PRINCIPAL PURPOSE: To identify and ensure that single military members and military couples with dependents have made adequate
dependent care arrangements and to ensure the member is world-wide assignable. The information which will be solicited is intended principally
for the following purposes: (a) The personal information will facilitate combat readiness and document a plan for the care of your family
members in the event of a medium or long term absence; (b) it will be used to evaluate compliance with the DOD and Navy programs requiring
Family Care Plans.
ROUTINE USES: To designate persons who will accept dependent care responsibility and to contact those persons to verify their willingness to
act for the member in this capacity, and to advise the designee(s) when they are expected to discharge these responsibilities. The information
may be used also to determine overseas suitability, to conduct authorized investigations, and for other lawful purposes.
DISCLOSURE IS MANDATORY: Disclosure of information concerning family members, their caregivers, and the personal arrangements
surrounding the care of family members is mandatory.
PART I. APPLIES TO ALL SINGLE SERVICEMEMBER SPONSORS
AND DUAL MILITARY COUPLES WITH DEPENDENTS
1. I have been counseled and fully understand Navy policy on dependent care responsibilities. I have read and understand the
INITIALS
Navy's policy that I must arrange for dependent care so that I will remain worldwide available as defined, and that I must report for
duty without dependents, as required.
2. I understand that failure to make and maintain an adequate Family Care Plan in accordance with the Navy's policy may be
grounds for disciplinary action or separation from the Navy, or both.
3. I understand that I may be subject to action under the Uniform Code of Military Justice if this statement is not accurate.
4. I understand that I am subject to deployments on short notice and that I will not be given special privileges because I have
dependents.
5. My normal working hours are
I have made arrangements for the care of my family members during these hours as well as
absences due to extended working hours and the execution of my military duties. I understand that if these arrangements for the
care of my dependents fail, my absence from assigned duty is without authority unless I have been excused by my commanding
officer.
6. I affirm that I have made and will maintain arrangements for the care of my dependents to permit me to be worldwide available
during Duty Hours, Extended Duty Hours, Exercises, Unaccompanied Tours, Temporary Additional Duty, Permanent Change of
Station, and other similar military obligations.
7. I understand that I must revise or verify this plan at least yearly or on reassignment, reenlistment, extension of enlistment, or
within 60 days (90 days for Ready Reserve) of any change in my family or caregiver status.
8. I understand that while serving in an overseas area, I must arrange for the escort to and care of my dependents by the
designated person. If my principal caregiver is not in the local area, I understand that I must arrange with a nonmilitary person in
the local area to assume temporary responsibility for my dependents until that responsibility is transferred to my principal
caregiver.
9. In the event of my death or incapacity, (name, address, telephone number) has agreed to assume temporary responsibility for
my minor children until the guardian named in my will assumes responsibility, or until a legal guardian or other custodian is
appointed by a court of competent jurisdiction, or until my child(ren)'s non-custodial natural parent assumes custody, whichever
occurs first.
10. The attached form (NAVPERS 1740/7) explains what financial arrangements have been made to provide support for my family
member(s) while they are under someone else's care, what logistical arrangements have been made to get my family members to
the designated caregiver; where to go for routine and emergency medical treatment for my family member(s), and what the
caregiver should do in the event they are no longer able to care for my family members.
PART II. APPLIES TO ALL SINGLE SERVICEMEMBER SPONSORS
AND DUAL MILITARY COUPLES WITH DEPENDENTS
11. I agree to accept responsibility and provide care for the family members of if he/she must report for duty for extended work hours, recall, or
TAD. I acknowledge that I have been fully briefed on : (a) Financial and logistical arrangements and location of important papers, (b) Military and
civilian support resources available to assist in the care of family members including location and/or points of contact for the member's
command, local Fleet and Family Support Center, child care center, and Navy Marine Corps Relief Society, and (c) Family member entitlements,
available services, and access requirements for military base resources including medical and dental treatment facilities, exchanges,
commissaries, and recreation facilities.
TYPED OR PRINTED NAME, RANK/RATE & SSN:
SIGNATURE:
DATE:
NAVPERS 1740/6 (REV. 09-06)
FOR OFFICIAL USE ONLY WHEN FILLED IN
S/N: 0106-LF-133-4700
PAGE 1 OF 2
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