Family Care Plan Checklist
Soldier’s Name: ____________________________ Unit: _______________________________
Single or Dual Military (Circle One) If Dual Military, Spouse’s Unit: _____________________
1. LOU between Commander and Soldier (Commander and Soldier)
2. ______ DA Form 5304-R, Family Care Plan Counseling Checklist, required if the soldier has
been counseled by the present Commander (or designee), after the 5305-R is complete the
5304-R is returned to the soldier (Commander [or designee] and Soldier)
3. ______ DA Form 5305-R, Family Care Plan Checklist (Commander and Soldier)
4. ______ DA Form 5841-R, Power of Attorney for Temporary Guardianship (short term),
Permanent Guardianship (long term) and Escort. Documents will be notarized - JAG. (Soldier)
5. ______DA Form 5840-R, Certificate of Acceptance as Guardian or Escort (notarized
6. ______ DD Form 1172, DD Form 1172, Application for Uniformed Services ID
Care/DEERS Enrollment (Soldier-also signed by ID Card NCOIC)
7. ______ DD Form 2558, Authorization to Start, Stop or Change an Allotment for Active Duty
or proof of other adequate financial arrangements for care of family members. (Soldier)
8. ______ A Letter of Instruction (LOI) outlining the specifics of the care arrangements made in
case duties preclude you from caring for your child. (Soldier)
9. If child(ren) is/are enrolled in any Army Childcare Delivery System a copy of the FCP is
required to be on file at the Child and Youth Services Division (AR608-10, Section 3, 4-6
Admission Criteria)
10. ______Picture(s) of child(ren)-optional (for safety)
Family Care Plan Update
Date Initials
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