
TELEPHONE NUMBER
(Include Area Code)
TYPED OR PRINTED NAME OF GUARDIAN
SIGNATURE DATE
(YYYY/MM/DD)
DDRESS
(Include ZIP Code)
E-MAIL ADDRESS
NOTARY:
STATE OF
COUNTY O
cknowledged before me this
My commission expires:
NAME
(s)
/ AGE
(s)
OF FAMILY MEMBERS
CERTIFICATE OF ACCEPTANCE AS GUARDIAN OR ESCORT
For use of this form, see AR 600-20; the proponent agency is DCS, G-1.
I
(Power of Attorney)
or other legally sufficient authority naming me as guardian/escort for:
was provided an original DA Form 5841
NAME
(s)
day of
family members of:
(Notary Public)
,.
DA FORM 5840, JUN 2010
PREVIOUS EDITIONS ARE OBSOLETE.
APD PE v1.00ES
I agree to accept responsibility for these family members. I have received all necessary documents
required to provide financial, medical, educational, quarters, and subsistence support for these family
members. I have been briefed on procedures for accessing military/civilian facilities, services, benefits,
and entitlements on behalf of these family members.
PRIVACY ACT STATEMENT
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy.
Guardian's agreement to care for a soldier's child(ren) in his or her absence.
None.
Voluntary; However, failure to provide all the requested information could lead to rejection of a soldier's
Family Care Plan.