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 certifying and accountable officers' appointments, and termination of those appointments. The
information will also be used for identification purposes associated with certification of documents and/or liability of public records and funds.
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
accountable individual 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 in the Federal Register.
DISCLOSURE: Voluntary; however, failure to provide the requested information may preclude appointment.
SECTION I - FROM: APPOINTING AUTHORITY
1. NAME (First, Middle Initial, Last)
3. DOD COMPONENT/ORGANIZATION
4. DATE (YYYYMMDD)
SECTION II - TO: APPOINTEE
6. NAME (First, Middle Initial, Last)
9. DOD COMPONENT/ORGANIZATION
10. ADDRESS (Include ZIP Code)
11. TELEPHONE NUMBER (Include Area Code)
12. EFFECTIVE DATE OF APPOINTMENT (YYYYMMDD)
13. POSITION TO WHICH APPOINTED (X as applicable (one only))
DEPUTY DISBURSING OFFICER
CHANGE FUND CUSTODIAN
IMPREST FUND CASHIER
DEPARTMENTAL ACCOUNTABLE OFFICIAL
14. YOU ARE HEREBY APPOINTED TO SERVE IN THE CAPACITY IDENTIFIED IN ITEM 13. YOUR RESPONSIBILITIES INCLUDE:
15. YOU ARE ADVISED TO REVIEW AND ADHERE TO THE FOLLOWING REGULATION(S) NEEDED TO ADEQUATELY PERFORM THE
DUTIES TO WHICH YOU HAVE BEEN ASSIGNED:
SECTION III - ACKNOWLEDGEMENT OF APPOINTMENT
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 under my control. I have been counseled on my pecuniary liability and have been given written operating
instructions. I certify that my official signature is shown in item 17 below.
16. PRINTED NAME (First, Middle Initial, Last)
SECTION IV - TERMINATION OF APPOINTMENT
18. DATE (YYYYMMDD)
19. APPOINTEE INITIALS
The appointment of the individual named above is hereby revoked.
20. NAME OF APPOINTING AUTHORITY
DD FORM 577, FEB 2011
PREVIOUS EDITION IS OBSOLETE.
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