Family Care Plan Counseling Checklist (Page 3 of 3) in pdf

Family Care Plan Counseling Checklist Page 3

SOLDIER

COMMANDER

PART II - ACTIVE COMPONENT (Continued)

H. The status of noncommand sponsored dependent family members in the overseas command. See paragraph

1-17, AR 55-46.

I. Services provided by the Army Community Services (ACS) regarding financial planning. See chapter 9, AR

608-1.

J. Services available from Personal Assistance Points at major points of embarkation in the CONUS.

K. Maternity counseling for pregnant single soldiers on the costs of child bearing and raising.

L. Provisions of CHAMPUS.

PART III - MILITARY SPOUSE AND SPOUSE'S COMMANDER CERTIFICATION

Military spouse: We have been counseled on our responsibilities to the military service and our dependent family member(s.)

1. SIGNATURE OF SPOUSE

2. DATE

3. TYPED OR PRINTED NAME OF SPOUSE

4. SSN

Spouse's commander: I have provided counseling for the military spouse assigned to my unit concerning Family Care Plan

requirements.

1. SIGNATURE OF SPOUSE'S COMMANDER

2. DATE

3. UNIT ADDRESS

4. TYPED OR PRINTED NAME OF SPOUSE'S COMMANDER

PART IV - SOLDIER AND COMMANDER CERTIFICATION

Soldier: I have been counseled on my responsibilities to the Army and to my dependent family member(s).

1. SIGNATURE OF SOLDIER

2. DATE

3. TYPED OR PRINTED NAME OF SOLDIER

4. SSN

Soldier's commander: I have provided counseling to the soldier on his/her responsibilities to the military service and to his/her

dependent family member(s).

1. SIGNATURE OF SOLDIER'S COMMANDER

2. DATE

3. UNITED ADDRESS

4. TYPED OR PRINTED NAME OF SOLDIER'S COMMANDER

PAGE 3, DA FORM 5304-R, MAR 92

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Family Care Plan Counseling Checklist Page 3