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

Dd Form 577 - Appointment Termination Record - Authorized Signature

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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)

2. TITLE

3. DOD COMPONENT/ORGANIZATION

4. DATE (YYYYMMDD)

5. SIGNATURE

SECTION II - TO: APPOINTEE

6. NAME (First, Middle Initial, Last)

7. SSN

8. TITLE

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))

DISBURSING OFFICER

DEPUTY DISBURSING OFFICER

DISBURSING AGENT

PAYING AGENT

CASHIER

COLLECTION AGENT

CHANGE FUND CUSTODIAN

IMPREST FUND CASHIER

CERTIFYING OFFICER

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)

17. SIGNATURE

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

21. TITLE

22. SIGNATURE

DD FORM 577, FEB 2011

PREVIOUS EDITION IS OBSOLETE.

Adobe Professional 8.0

Dd Form 577 - Appointment Termination Record - Authorized Signature

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