Fillable Dd Form 577 - Appointment/termination Record - Authorized Signature printable pdf download

APPOINTMENT/TERMINATION RECORD - AUTHORIZED SIGNATURE

(Read Privacy Act Statement and Instructions before completing form.)

PRIVACY ACT STATEMENT

AUTHORITY:

E.O. 9397, 31 U.S.C. Sections 3325, 3528, DoDFMR, 7000.14-R, Vol. 5.

PRINCIPAL PURPOSE(S): To maintain a record of appointment and termination of appointment of persons to any of the positions listed in Item 6,

and to identify the duties associated with this appointment.

SORN T1300 ( )

ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C Section 552a(b) of the Privacy Act of 1974,

as amended. It may also be disclosed outside of the Department of Defense (DoD) to the the Federal Reserve Banks to verify authority of the

appointed individuals to issue Treasury checks. In addition, other Federal, State and local government agencies, which have identified a need to

know, may obtain this information for the purpose(s) identified in the DoD Blanket Routine Uses published at:

DISCLOSURE Voluntary; however, failure to provide the requested information may preclude appointments.

SECTION I - APPOINTEE

1. NAME (First, Middle Initial, Last and Rank or Grade)

2. DoD ID NUMBER

3. TITLE

4. DOD COMPONENT/ORGANIZATION

5. ADDRESS

(Include ZIP Code, email address, and telephone number with area code and DSN)

6. POSITION TO WHICH APPOINTED (X appropriate box - one only. Checking more than one invalidates the appointment.)

DISBURSING OFFICER: DSSN

CASHIER

CHANGE FUND CUSTODIAN

DEPUTY DISBURSING OFFICER: DSSN

PAYING AGENT

IMPREST FUND CASHIER

CERTIFYING OFFICER

COLLECTIONS AGENT

SAFEKEEPING CUSTODIAN

DEPARTMENTAL ACCOUNTABLE OFFICIAL

DISBURSING AGENT

ASSISTANT SAFEKEEPING CUSTODIAN

7. YOU ARE APPOINTED TO SERVE IN THE POSITION IDENTIFIED IN ITEM 6. YOUR RESPONSIBILITIES INCLUDE:

Perform Duties as a Non-DTS Entry Agent (NDEA).

Create and sign or T-Enter authorizations, vouchers, and local vouchers (documents shall only be signed or T-Entered for travelers without

reasonable access to DTS such as non-CAC holders). Receive a manually prepared and signed DD Form 1351-2, Voucher or SF1164, Local

Voucher from the traveler. You shall scan or fax these documents and all applicable receipts into the DTS voucher. When you sign the DTS

voucher for the traveler, you certify that the information contained in the traveler's manually prepared and signed voucher is entered as claimed on

that voucher. You are not responsible for the validity of the data for the manual voucher signed by the traveler. You do not have the authority to

obligate funds or to certify travel documents for payment. The NDEA must comply with all requirements of the Privacy Act of 1974. Any use of

DTS information for other than official business may subject the NDEA to possible criminal penalties and/or administrative sanctions.

8. REVIEW AND ADHERE TO THE FOLLOWING PUBLICATION(S) NEEDED TO ADEQUATELY PERFORM YOUR ASSIGNED DUTIES:

DoD FMR Vol. 9, Chapter 2. MCO 4650.39A

SECTION II - APPOINTING AUTHORITY

9. NAME (First, Middle Initial, Last)

10. TITLE

11. DOD COMPONENT/ORGANIZATION

13. SIGNATURE

12. DATE (YYYYMMDD)

SECTION III - APPOINTEE ACKNOWLEDGEMENT

I acknowledge and accept the position and responsibilities defined above. I understand that I am strictly liable to the United

States for all public funds or payment certification, as appropriate, under my control. I have been counseled on my pecuniary liability

applicable to this appointment and have been given written operating instructions. I certify that my official signature is shown in item

16 below.

14. PRINTED NAME (First, Middle Initial, Last)

15. DATE (YYYYMMDD)

(Not earlier than date in Item 12 or 13)

16.a. DIGITAL SIGNATURE

16.b. MANUAL SIGNATURE

SECTION IV - APPOINTMENT TERMINATION

17. DATE (YYYYMMDD)

18. APPOINTEE INITIALS

The appointment of the individual named above is

hereby revoked.

19. NAME OF APPOINTING AUTHORITY

20. TITLE

21. APPOINTING AUTHORITY SIGNATURE

DD FORM 577, NOV 2014

PREVIOUS EDITION IS OBSOLETE.

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Dd Form 577 - Appointment/termination Record - Authorized Signature

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