ADMINISTRATIVE SEPARATION GUIDE
When Company Commanders decide to consider a soldier for separation, they should
reference this guide to help expedite the administrative separation process. This guide can
answer some frequently asked questions pertaining to most chapters. The 108th Air Defense
Artillery Legal Office should be contacted to consult with a legal representative before any
administrative separation actions should begin. Multiple steps are involved in this process, and
careful planning in the beginning will lead to the soldier being separated in a timely manner.
To separate a soldier using the notification procedure (service members in the grade of E-1
through E-4 with less than 6 years of service only), please follow the procedures listed below.
After contacting the 108th Air Defense Artillery Brigade Legal Office, commanders should use
the appropriate contact numbers according to the type of chapter the soldier is to receive, to
schedule appointments for their soldiers. Only schedule the appointments that are necessary for
the chapter.
Medical Exams (7-7639) – Appointments have to be made by the Commander or First Sergeant
and should be made the day that it is decided that the SM will be separated (After contacting the
Brigade Legal Office). Medical exams are done every Wednesday at 0715 hours (If the SM is
late, they will not be seen). Currently, the SM will be seen on that Wednesday or the following
week. Also, if an appointment cannot be made, walk-ins will be accepted based on the number
of patients that are present. The SM will be in PFU’s and escorted by an NCO (E-5 or above), if
E-4 or below, and by a senior NCO if an E-5 or above. The escort will need to ensure that the
SM has their medical records and has a Letter of Intent stating that the SM is pending separation.
Additionally, the SM will be instructed to “fast” the night before the exam, bring glasses (No
contacts) and to bring a black pen.
Mental Exams (7-6825) – Appointments have to be made by the Commander or First Sergeant
and should be made the day that it is decided that the SM will be separated (After contacting the
Brigade Legal Office). Mental exams are done every Thursday at 1230 hours (If the SM is late,
they will not be seen). Currently, the SM will be seen on that Thursday. No walk-ins will be
allowed. The SM will be escorted by an NCO (E-5 or above), if E-4 or below, and by a senior
NCO if an E-5 or above. FB Form 1462 will be filled out, in it’s entirety, by the Commander and
given to the escort to turn in at the Behavioral Medicine Clinic.
ACAP (6-7188) – ACAP is located in the 18th SSG (Old WAMC building). The SM must pickup an ACAP Checklist as soon as the command has decided that the SM will be separated.
Education Counseling (6-8953) – The education counseling will be done on a walk-in basis,
0900-1700, Monday – Friday. 108th Air Defense Artillery soldiers will be seen at the Smoke
Bomb Hill education center.
i
Debt Avoidance Counseling (6-2238) – Debt avoidance counseling will be done on a walk-in
basis 0900-1600, M-T-Th-F. Finance is located on the Second Floor, First Citizens Bank, Reilly
Road, across the street from the NCO Club (in the Mini-Mall parking lot).
COMMANDERS AND FIRST SERGEANTS WILL CONSULT WITH THEIR UNIT
PARALEGAL TO OBTAIN GUIDANCE ON NECESSARY DOCUMENTS. THIS DOES
NOT CONSTITUTE TURNING A SEPARATION PACKET IN; HOWEVER, TO
INSURE TIMELINESS, PARALEGALS WILL NOTIFY THE BRIGADE LEGAL NCO
WHEN ADMINISTRATIVE PROCEEDINGS HAVE BEEN STARTED. THIS
MEETING IS A SERVICE TO THE UNIT TO PROVIDE GUIDANCE ON THE
ADMINISTRATIVE SEPARATION PROCESS. INCOMPLETE PACKETS WILL NOT
BE ACCEPTED. ALL DOCUMENTS (i.e. LEGAL ACTION REQUEST, ERB, 2-1, and
FLAG) MUST BE IN PACKET TO BE ACCEPTED. PLEASE DO NOT ASK THE
PARALEGAL TO COMPROMISE STANDARDS.
ii
ADVERSE ADMINISTRATIVE SEPARATION (CHAPTER) GUIDE
INDEX
CHAPTER
5-3: Secretarial Authority
5-8: Parenthood (Lack of Family Care Plan)
5-11: Fail to Meet Procurement Medical Fitness Standards
5-13: Personality Disorder
5-16: School Drop
5-17: Other Physical or Mental Disorder
6: Dependency/Hardship
7: Fraudulent Enlistment
8: Pregnancy
9: ASAP Rehab Failure
10: Separation In Lieu of Trial by Court-Martial
11: Entry Level Performance
13: Unsatisfactory Performance
14-5: Civil Court Conviction
14-12b: Pattern of Misconduct
14-12c: Commission of a Serious Offense
15: Homosexuality
18: Overweight
Revoking a Suspended Chapter
____
APPENDICES:
A: Request for Separation
B: 1-16 "MAGIC" Counseling,
C: Debt Avoidance Counseling
D: Education Benefits Counseling
E: Family Care Plan & Counseling, DA Forms 5304-R & 5305-R
F: Pregnancy Counseling Checklist & Statement of Pregnancy Counseling
G: Weight Control Supporting Documentation
H: DA Form 4187 - Chapter 5-3
I: Form 4187 - Chapter 6 - Hardship
J: DA Form 4187 - Chapter 6 - Dependency
K: DA Form 4187 - Chapter 8 - Pregnancy
L: DA Form 4187 - Chapter 16-5c - Request for Elimination because of DCSS
PAGE(S)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18,19
20
21
22
23
24
25-28
29
30-32
33
35
36
37
39
iii
CHAPTER 5-3: SECRETARIAL PLENARY AUTHORITY (“ONCE IN A LIFETIME
OPPORTUNITY”)
This provision of AR 635-200 provides for those soldiers who desire to leave active duty but
who do not qualify under any other provision of AR 635-200. Recent guidance (MILPER
Message NR 97-095) emphasizes that requests under this provision will not be approved unless
discharge is clearly “in the best interests of the Army,” not necessarily in the best interests of
the soldier. Individual requests which serve only the interest of the soldier, particularly those
involving soldiers with critical military skills or bonus recipients, will not be approved except
under exceptional circumstances. Requests for separation more than three months before ETS
normally will be disapproved.
This chapter action is processed at the unit level (S1). Unit Commanders must understand
that this chapter is approved at the Secretary of the Army level. This chapter is requested by
the soldier on a DA Form 4187 which is forwarded through the chain of command and
transmitted via fax (DSN: 221-1965) to HQDA, ATTN: TAPC-PDT-S. Chain of command
forwarding endorsements must indicate rationale to support determination that early separation is
in the best interest of the Army as well as a statement whether the soldier has received education
benefits counseling. In addition, chain of command forwarding endorsements must recommend
approval or disapproval and, if recommending approval, include a recommendation concerning
characterization of service (either Honorable, or General, Under Honorable Conditions).
1-16 counseling Required: No (1-16a)
Medical Required: No (1-34a)
Mental Required: No (1-34b)
Approval Authority: HQDA (TAPC-PDT-S) (5-3e)
Type of discharge authorized: Honorable or General, Under Honorable Conditions (6-11)
Documents Required for Chapter:
( ) DA Form 4187 from soldier (See example - Appendix I). The DA Form 4187 will be
approved/disapproved by the Company Commander and forwarded through the chain of
command by endorsement to the approval authority. The intermediate commander(s) will either
disapprove the request or recommend approval and if recommending approval, will specify
which characterization of discharge is appropriate, either Honorable, or General, Under
Honorable Conditions.
( ) Statement from soldier explaining in detail why approval of request would be in “the best
interest of the military”.
( ) Affidavit or statement from agency substantiating soldier’s stated reason for elimination (i.e.
letter from employer detailing better job opportunity to include intent to hire, better salary or
affidavit detailing lottery winnings).
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) DA Form 2A
( ) DA Form 2-1 and ERB
( ) ACAP Checklist
1
CHAPTER 5-8: INVOLUNTARY SEPARATION DUE TO PARENTHOOD
(LACK OF AN ADEQUATE FAMILY CARE PLAN)
Soldiers must arrange for the care of their family members so as to be available for duty when
and where the needs of the Service dictate; be able to perform assigned military duties without
interference; and remain eligible for worldwide assignment. Soldiers will be considered for
involuntary separation when parental obligations interfere with fulfillment of military
responsibilities. IAW para 5-5, AR 600-20, the following soldiers are required to maintain an
adequate family care plan:
1. If the soldier is MARRIED to another member of the Army or a member of another
service and IF:
a. Soldier has joint physical or legal custody of one or more children under age 18 OR
b. Soldier has a family member incapable of self-care regardless of age.
2. If the soldier is SINGLE and IF
a. Soldier has physical and legal custody of one or more children under age 18 OR
b. Soldier has family members incapable of self-care regardless of age.
1-16 Counseling Required: Yes, (5-8b)(1-16a(1))
Medical Required: No (1-34a)
Mental Required: No (1-34b)
Approval Authority: Bde Cdr (1-21c(1))
Type of Discharge Authorized: Honorable or General, Under Honorable Conditions (5-1a)
Note: Command does not have to wait the full amount of time (30 days) before initiating IF
soldier provides statement-stating inability to provide an adequate family care plan now or in the
future.
Documents Required for Chapter:
( ) Request for separation
( ) DA Form 5304-R, Family Care Counseling Checklist (See example - Appendix E)
( ) DA Form 5305-R, Family Care Plan (See example - Appendix E)
( ) All counseling statements including 1-16 "magic" counseling statement (See example Appendix B) regarding inability to perform due to parenthood
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
( ) ACAP Checklist
2
CHAPTER 5-11: SEPARATION OF PERSONNEL WHO DID NOT MEET
PROCUREMENT MEDICAL FITNESS STANDARDS
Soldiers who were not medically qualified under procurement medical fitness standards at
enlistment will be separated. Medical proceedings must show that an appropriate military
medical authority (PA or Doctor) identified a medical condition within 6 months of the soldier’s
initial entrance on Active Duty, which:
1. Would have disqualified the soldier for entry into the military had it been detected in time;
and
2. Does not disqualify the soldier for retention in the military UP AR 40-501, Chapter 3 (If a
medical authority identifies a soldier with a disqualifying condition for retention in the military
that did not exist at the time of enlistment, the soldier will not be processed for elimination under
this provision. Rather, the soldier will be processed under MEB/PEB procedures).
1-16 counseling Required: No (1-16a)
Medical Required: Yes (must show disqualifying condition identified w/in 6 months of entry)
Mental Required: No (1-34b)
Approval Authority: Bde Cdr (1-21c(1))
Type of discharge authorized: Honorable or General, Under Honorable Conditions (5-1(a))
Documents Required for Chapter:
( ) Request for separation
( ) Evidence of medical proceedings that shows the soldier has a disqualifying condition that
was identified w/in 6 months of entry on AD.
( ) Entrance medical showing no waiver of disqualifying condition was granted.
( ) Statement from medical officer that the identified medical condition does not disqualify the
soldier for retention in the military UP AR 40-501, chapter 3.
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
( ) ACAP Checklist
3
CHAPTER 5-13: SEPARATION BECAUSE OF PERSONALITY DISORDER
Soldiers will be considered for involuntary separation when diagnosed with a personality
disorder that interferes with assignment to or performance of duty.
1-16 counseling Required: Yes (1-16a(2))
Medical Required: No (1-34a)
Mental Required: Yes (1-34b)
Approval Authority: Bde Cdr (1-21c(1))
Type of discharge authorized: Honorable (5-13h)
Documents Required for Chapter:
( ) Request for separation
( ) Mental Examination signed by Psychiatrist or Licensed Clinical Psychologist
recommending separation under AR 635-200, Chapter 13 because the soldier has a mental
condition which is a deeply-ingrained maladaptive pattern of behavior of long duration.
( ) All counseling statements including 1-16 "magic" counseling statement (See example Appendix B) describing inability to perform because of personality disorder
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
( ) ACAP Checklist
4
CHAPTER 5-16: EARLY SEPARATION TO FURTHER EDUCATION
Soldiers may be discharged or released from active duty for the convenience of the Government,
up to 90 days before ETS, in order to attend a specific term at a college, university, vocational
school, or technical school. However, soldiers serving their initial enlistment of less than 3
years are ineligible for separation under this chapter. IAW para 5-17, AR 635-200, to
qualify for early separation, eligible soldiers must:
1. Not be mission essential to their assigned organizations, as determined by their immediate
commanders.
2. Clearly establish that the specific school term for which they seek early separation is
academically the most opportune time for them to begin or resume their education, and that delay
of school enrollment until normal ETS would cause undue personal hardship.
3. Provide a statement from an appropriate school official (for example, a registrar or director
of admissions) indicating acceptance for enrollment (as opposed to enrollment on a stand-by
basis, or enrollment on a probationary status) in a full-time resident course of instruction.
4. Show that they are able to pay, or have already paid, any school entry fees.
This chapter action is processed at the unit level (S1). This chapter is requested by the soldier
on a DA Form 4187, that is forwarded through the chain of command for action by the Brigade
Commander.
1-16 counseling Required: No (1-16a)
Medical Required: No (1-34a)
Mental Required: No (1-34b)
Approval Authority: Bde Cdr (1-21c(1))
Type of Discharge Authorized: Honorable or General, Under Honorable Conditions (5-1a)
Documents Required for Chapter:
( ) DA Form 4187 from soldier (See example - Appendix J). The DA Form 4187 will be
approved/disapproved by the Company Commander and forwarded through the chain of
command by endorsement to the approval authority. The intermediate commander(s) will either
disapprove the request or recommend approval and if recommending approval, will specify
which characterization of discharge is appropriate, either Honorable, or General, Under
Honorable Conditions.
( ) Statement from soldier informing chain of command of the reasons why they should approve
request to leave the military 90 days before the scheduled ETS date.
( ) Affidavit or statement from school registrar or director of admissions stating that soldier is
enrolled as a full time student. If affidavit shows that soldier is enrolled on a stand-by basis or
enrolled in a probationary status, chapter cannot be approved and soldier will have to wait for
normal ETS before attending school.
( ) Financial evidence (i.e., enrollment receipts, bank statement) which demonstrate that the
soldier can or already has paid for any school entry fees.
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
5
CHAPTER 5-17: SEPARATION BECAUSE OF OTHER PHYSICAL OR MENTAL
CONDITION
Soldiers will be considered for involuntary separation under this paragraph on the basis of Other
physical or mental conditions not amounting to disability (AR 635-40) (excluding conditions
appropriate for separation processing under paragraph 5-11 or 5-13), that potentially interfere
with assignment to or performance of duty. IAW para 5-18a, AR 635-200, such conditions may
include, but are not limited to, suicidal tendencies, chronic airsickness or seasickness,
sleepwalking, dyslexia, severe nightmares, claustrophobia, and other disorders manifesting
disturbances of perception, thinking, emotional control or behavior sufficiently severe that the
soldier’s ability to effectively perform military duties is significantly impaired.
1-16 counseling Required: Yes (1-16a(2))
Medical Required: Yes (1-34a) (if separation based on physical condition)
Mental Required: Yes (1-34b) (if separation based on mental condition)
Approval Authority: Bde Cdr
Type of discharge authorized: Honorable (5-13h)
Documents Required for Chapter:
( ) Request for separation
( ) Mental Examination (if basis is for mental condition) signed by Psychiatrist or Licensed
Clinical Psychologist
( ) Medical Examination (if basis is for physical conditions)
( ) All counseling statements including 1-16 "magic" counseling statement (See example Appendix B) describing inability to perform because of mental or physical condition.
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) DA Form 2-1 and ERB
( ) FLAG for elimination
( ) ACAP Checklist
6
CHAPTER 6: SEPARATION BECAUSE OF DEPENDENCY OR HARDSHIP
This Chapter action is processed at the unit level (S-1). This chapter is requested by the
soldier to be discharged for Dependency or Hardship. Pursuant to AR 635-200, paragraph 6-3, a
“Dependency exists when death or disability of a member of a soldier's (or spouse's) immediate
family causes that member to rely upon the soldier for principal care or support". Paragraph 6-3,
AR 635-200 states that a "Hardship exists when in circumstances not involving death or
disability of a member of the soldier's (or spouse's) immediate family, separation from the
Service will materially affect the care or support of the family by alleviating undue or genuine
hardship".
A married soldier who becomes a parent by birth, adoption or marriage (stepparent), and whose
child (or children) under 18 years of age reside within the household, may apply for separation
under hardship. The soldier must submit evidence that the roles of parent and soldier are
incompatible and that they cannot fulfill their military obligation without neglecting the child or
children.
1-16 counseling Required: No (1-16a)
Medical Required: No (1-34a)
Mental Required: No (1-3b)
Approval Authority: Bde Cdr (1-21c(1))
Type of discharge authorized: Honorable or General, Under Honorable Conditions (6-11)
Documents Required for Chapter:
( ) DA Form 4187 or Affidavit from soldier explaining conditions (See example at Appendix K
if request is for Hardship or Appendix L if request is for Dependency). DA Form 4187 will be
approved/disapproved by the Company Commander and forwarded through the chain of
command by endorsement to the Brigade Commander (Battalion Commander for Separate
Battalions). The intermediate commander(s) will either disapprove the request or recommend
approval and if recommending approval, will specify which characterization of discharge is
appropriate, either Honorable, or General, Under Honorable Conditions.
( ) Affidavit or statement from family member on behalf of the soldier substantiating the
dependency or hardship claim.
( ) Affidavits by at least 2 agencies or individuals other than family members substantiating the
dependency or hardship claim (i.e. Red Cross, Chaplain, Family Physician).
( ) Detailed statement to establish monthly income and expenses (If the basis is financial
difficulty).
( ) Death certificate or valid proof of death in the family (If the basis is because of a death).
( ) Physicians statement with diagnosis and date of disability (If the basis is because of a
disability).
( ) If sole parenthood results from divorce or legal separation, a judicial decree or court order
awarding child custody to the soldier will also be included.
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
7
CHAPTER 7: FRAUDULENT ENLISTMENT
Fraudulent enlistment is the procurement of an enlistment, reenlistment, or period of active
service through any deliberate material misrepresentation, omission, or concealment of
information that, if known and considered by the Army at the time of enlistment or reenlistment,
might have resulted in rejection. Some examples of fraudulent enlistment are:
1. Concealment of Prior Service
2. Concealment of True Citizenship Status
3. Concealment of Conviction by Civil Court
4. Concealment of Record as a Juvenile Offender
5. Concealment of Medical Defects
6. Concealment of Absence Without Leave or Desertion from Prior Service
7. Concealment of Pre-service Homosexuality
8. Misrepresentation of Intent with Regard to Legal Custody of Children1
9. Concealment of other disqualifications2
1
Paragraph 7-17(8) reads “Soldiers who were applicants without a spouse at the time of
enlistment and who executed the certificate required by AR 601-210 will be processed for
separation for fraudulent entry if custody of the children is regained by court decree, as provided
by State law, or as a result of the children resuming residency with the soldier instead of the legal
custodian. Because the soldier certified at enlistment that the custody arrangement was intended
to remain in full force and effect during the term of enlistment, the burden is on the soldier to
demonstrate that the regaining of custody is not contrary to statements made at the time of
enlistment.”
2
One possible disqualification concerns the failure to disclose a civilian conviction or illegal drug
use before entry on active duty. A typical scenario is a soldier tests positive for using an illegal
drug. During the subsequent interview with CID, the soldier admits to using illegal drugs before
entry on active duty. A check of the soldier’s enlistment contract fails to admit illegal drug use
or fails to admit a civilian conviction before entry on active duty. Soldier qualifies for separation
under this chapter for fraudulent entry.
1-16 Counseling Required: No (1-16a)
Medical Required: No (1-34a)
Mental Required: No (1-34b)
Approval Authority: Bde Cdr (1-21c(1))
Type of discharge authorized: Honorable or General, Under Honorable Conditions (7-23)
Remarks: IAW AR 635-200, para 7-20b(4), once the separation authority approves the
discharge, the separation authority CANNOT SUSPEND the execution of the approved
discharge.
Documents Required for Chapter:
( ) Request for separation
( ) Enlistment contract
( ) Evidence of enlistment fraud
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) FLAG for elimination
8
CHAPTER 8: SEPARATION OF ENLISTED WOMEN - PREGNANCY
This chapter action is processed at the unit level (S1). When an enlisted woman is pregnant,
she will be counseled by the unit commander using the Pregnancy Counseling Checklist
(Reproduced at Appendix F). As per the guidance found in Chapter 8-9, AR 635-200, the unit
commander will explain that the purpose of the counseling is to provide information concerning
options, entitlements, and responsibilities and that she may elect to remain on active duty or,
upon request, be separated per this chapter. The soldier may request a specific separation date,
but the Battalion Commander and her military physician will determine the separation date. The
date must not be later than 30 days before expected date of delivery or the latest date her military
physician will authorize her to travel to her home of record. Commanders processing a soldier
under this chapter must also understand the following guidelines:
1. If a soldier carries a pregnancy for 16 weeks or more, but then has an abortion,
miscarriage, or an immature or premature delivery before separation is accomplished, the soldier
will have the option to be retained or be separated per this chapter (para 8-8f).
2. An enlisted woman who elects to remain on active duty when counseled may, if she is still
pregnant, subsequently request separation. The Battalion Commander must separate the soldier,
but may set the separation date (para 8-8g).
3. An enlisted woman who requested separation in writing may subsequently request
withdrawal of the separation request. The Battalion Commander, based on the circumstances of
the case and the best interest of the Army, will determine in writing if the soldier is to be
separated or retained (para 8-8h).
1-16 Counseling Required: No (1-16a) but Immediate Commander will counsel soldier using
Pregnancy Counseling Checklist located on page 76, AR 635-200 (example at Appendix E)
Medical Required: Yes (1-34a)
Mental Required: No (1-34b)
Approval Authority: Bn Cdr (1-21d)
Type of discharge authorized: Honorable or General, Under Honorable Conditions (8-3)
Documents Required for Chapter:
( ) Medical Examination establishing Pregnancy. SF Forms 88 and 93 will be used by the
Physician to establish pregnancy.
( ) Pregnancy Counseling Checklist (see example at Appendix E)
( ) Statement of Pregnancy Counseling (Part II of the Pregnancy Counseling Checklist) signed by
pregnant soldier (example at Appendix F).
( ) DA Form 4187 requesting separation UP AR 635-200, Chapter 8. (See example at Appendix
M). DA Form 4187 will be approved/disapproved by the Company Commander and forwarded
to Battalion Commander who must approve the request, but can set the separation date. The
Battalion Commander must also indicate which characterization of discharge is appropriate,
either Honorable, or General, Under Honorable Conditions.
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
9
CHAPTER 9: ALCOHOL OR OTHER DRUG REHABILITATION FAILURE
This chapter provides the authority for discharging soldiers for alcohol or other drug abuse
rehabilitation failure. Discharge of a soldier occurs when the commander feels that further
rehabilitation efforts are not practical, rendering the soldier a rehabilitation failure. This
determination will be made in consultation with the rehabilitation team (ADAPCP Counselor).
As per 9-2c, AR 635-200, initiation of separation proceedings is required for soldiers designated
as alcohol/drug rehabilitation failures.
1-16 Counseling Required: No (1-16a)
Medical Required: Yes (1-34a)
Mental Required: No (1-34b)
Approval Authority: Bn Cdr if notification procedure used, otherwise Bde Cdr (1-21d)
Type of discharge authorized: Honorable or General, Under Honorable Conditions (9-4)
Remarks: Read ADAPCP counselor's report. If self-referral is mentioned in the report and the
report is used as the basis for declaring the soldier a rehabilitation failure, the soldier will be
entitled to receive an Honorable Discharge, as per guidance found in AR 600-85, paragraph 6-4.
Documents Required for Chapter:
( ) Request for separation
( ) Statement from ADAPCP Counselor indicating rehabilitation failure
( ) Medical examination
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
10
CHAPTER 10: SEPARATION IN LIEU OF COURT-MARTIAL
This chapter is not and cannot be a command-initiated chapter. This chapter is requested
by the soldier though the U.S. Army Trial Defense Service. In order to qualify to request this
type of chapter, the soldier must have committed an offense or offenses, the punishment for
which, under the UCMJ and the MCM, 1995, includes a bad-conduct discharge or dishonorable
discharge. Charges for court-martial must be preferred against the Soldier before he/she can
request a Chapter 10 through their Defense Counsel.
1-16 Counseling Required: No (1-16a)
Medical Required: No (1-34a)
Mental Required: No (1-34b)
Approval Authority: CG (1-21a)
Type of discharge authorized: Honorable or General, Under Honorable Conditions or Under
Other Than Honorable (UOTH) Conditions Discharge (10-8)
11
CHAPTER: 11 ENTRY LEVEL PERFORMANCE AND CONDUCT
In order for a soldier to qualify for this chapter, the command must initiate the chapter while
the soldier is on the initial 180 days of continuous active military service. Soldier qualifies for
separation under this chapter if the soldier displays unsatisfactory performance or minor
disciplinary infractions as evidenced by inability, lack of reasonable effort, or failure to adapt to
the military environment. Pursuant to paragraph 11-3d, if a soldier is in an entry-level
status and qualifies for separation for unsatisfactory performance (Chapter 13) or for a
Pattern of Misconduct (14-12b), separation processing will be accomplished under this
chapter.
1-16 counseling Required: Yes (1-16a(3))
Medical Required: No (1-34a) but check 11-3b for pregnant females.
Mental Required: No (1-34b)
Approval Authority: Bn Cdr (1-21d)
Type of discharge authorized: Uncharacterized (11-8)
Remarks: If BASD and information on DA Form 2A conflict, then the dates on the enlistment
contract will start the clock.
Documents Required for Chapter:
( ) Request for separation
( ) All counseling statements including 1-16 "magic" counseling statement (See example Appendix B) describing soldier's inability to adapt to the military environment.
( ) Debt avoidance counseling
( ) Education benefits counseling
( ) DA Form 2A
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
12
CHAPTER 13: SEPARATION FOR UNSATISFACTORY PERFORMANCE
Commanders will separate a soldier for unsatisfactory duty performance when it is determined
that the soldier will not develop sufficiently to participate satisfactorily in further training and/or
become a satisfactory soldier; or the seriousness of the circumstances is such that the soldier's
retention would have an adverse impact on military discipline, good order, and morale; and it is
likely that the soldier will be a disruptive influence in present or future duty assignments.
Pursuant to para 13-2f, AR 635-200, initiation of separation proceedings is required for soldiers
without medical limitations who have two consecutive failures of the Army Physical Fitness or
who are eliminated for cause from Noncommissioned Officer Education System (NCOES)
courses, unless the responsible commander chooses to impose a bar to reenlistment.
1-16 counseling Required: Yes (13-4 or 1-16a(4))
Medical Required: Yes (1-34a)
Mental Required: Yes (1-34b)
Approval Authority: Bn Cdr if notification procedure used, otherwise Bde Cdr (1-21d)
Type of discharge authorized: Honorable or General, Under Honorable Conditions (13-11).
A discharge Under Other Than Honorable Conditions (UOTH) is not authorized (3-7c(4))
Remarks: AR 350-41, Training in Units (pg 17) and FM 21-20 Physical Fitness Training
(pg. 14-11) both state that in the event of a record test failure, commanders may allow soldiers to
retake the test as soon as the soldier and the commander feel the soldier is ready. Soldiers
without a medical profile will be retested no later than 3 months following the initial APFT
failure. When a soldier fails the initial record APFT, the soldier will be counseled using the 116 "magic" counseling statement and informed of the date of their next record APFT which, for
the purposes of this chapter, must be scheduled before the 90 days have expired. Soldiers do not
have to wait for the next scheduled record APFT date and can request, in writing, that they be
able to retake the record APFT as soon as they are ready. The soldier must indicate, in writing,
that they understand the ramifications of retaking the record APFT before the allowed time and
express their understanding that if they fail the second record APFT, they can be separated.
Documents Required for Chapter 13:
( ) Request for separation
( ) All counseling statements including 1-16 "magic" counseling statement (See example Appendix B), especially important after initial APFT failure.
( ) For APFT failures: DA Form 705 - APFT Scorecard with "record" and at least 90 days in
between record APFTs. If the time between record APFTs does not equal 90 days, also
include the statement from the soldier indicating their desire to retake the test before the required
waiting period has expired. For NCOES disciplinary drops: Any documents reflecting
soldier's disenrollment from the school, especially DA Form 1059.
( ) Medical examination
( ) Mental examination
( ) Debt avoidance counseling
( ) Education benefits counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) DA 268 - Flag for elimination
13
CHAPTER 14-5: CONVICTION BY CIVIL COURT
A soldier may be considered for discharge when convicted by civil authorities when a punitive
discharge (Bad-Conduct Discharge or Dishonorable Discharge) would be authorized for the same
or a closely related offense under the MCM, 1984, as amended in 1995, or when the sentence by
civil authorities includes confinement for 6 months or more, without regard to suspension or
probation.
1-16 counseling Required: No (1-16a)
Medical Required: No (1-34a)
Mental Required: No (1-34b)
Approval Authority: Bde Cdr (1-21c(2)(a), unless UOTH, then CG must approve.
Type of discharge: Honorable or General, Under Honorable Conditions - Bde Cdr can approve
ONLY if notification procedure used. If board procedures used because of UOTH
recommendation, only CG can approve discharge, whether Honorable or General, Under
Honorable Conditions or Under Other Than Honorable (UOTH) Conditions.
Remarks: Initiation of separation action is NOT mandatory. (14-5b)
NOTE: When a soldier waives his or her right to a hearing before an administrative separation
board because of an UOTH recommendation, the case will be processed without convening a
board. However, the separation authority (CG) will be the same as if the board was held (2-5a).
Documents Required for Chapter:
( ) Request for separation
( ) Any court documents reflecting the conviction by civil authorities and the sentence imposed.
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) FLAG for elimination
14
CHAPTER: 14-12b ACTS OR PATTERNS OF MISCONDUCT
Soldiers are subject to separation per this chapter for the discreditable involvement with civil or
military authorities and/or conduct prejudicial to good order and discipline. Discreditable
conduct and conduct prejudicial to good order and discipline includes conduct that violates
accepted standards of personal conduct found in the UCMJ, Army Regulations, the civil law, and
time-honored customs and traditions of the Army.
1-16 counseling Required: Yes (1-16a(5))
Medical Required: Yes (1-34a)
Mental Required: Yes (1-34b)
Approval Authority: Bde Cdr, (1-21c(2)(a)), unless UOTH, then CG must approve.
Type of discharge: Honorable, General, Under Honorable Conditions - Bde Cdr can approve
ONLY if notification procedure used. If board procedures used because of UOTH
recommendation, only CG can approve discharge, whether Honorable or General, Under
Honorable Conditions or Under Other Than Honorable (UOTH) Conditions.
REMARKS: When a soldier waives his or her right to a hearing before an administrative board
because of an UOTH recommendation, the case will be processed without convening a board.
However, the separation authority (CG) will be the same as if the board was held (2-5a).
Documents Required for Chapter:
( ) Request for separation
( ) Counseling statements including 1-16 "magic" counseling statement (See example Appendix B) detailing soldier's pattern of misconduct.
( ) Evidence of misconduct to include Summary Courts-Martial Result of Trial (DA Form 2329)
to include JAG Review Endorsement, Article 15s, bad check notification, letter of reprimand, bar
to reenlistment, DA Form 4187s for AWOL, etc.
( ) Medical examination
( ) Mental examination
( ) Education benefits counseling
( ) Debt avoidance counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
15
CHAPTER: 14-12c COMMISSION OF A SERIOUS OFFENSE
A soldier may be separated for the commission of a serious offense if the specific circumstances
of the offense warrant separation and a punitive discharge would be authorized for the same or a
closely related offense under the MCM, or for the following reasons:
1. An absentee returned to military control from a status of AWOL or desertion may be
separated for commission of a serious offense.
2. Abuse of illegal drugs is serious misconduct. All violators must be processed for
separation.
1-16 counseling Required: No (1-16a)
Medical Required: Yes (1-34a)
Mental Required: Yes (1-34b)
Approval Authority: Bde Cdr (1-21c(2)(a)), unless UOTH, then CG must approve.
Type of discharge: Only Honorable or General, Under Honorable Conditions - Bde Cdr, can be
approved if notification procedures are used. (A Bde Cdr can only approve a Ch 14-12.c. with
an Honorable Discharge if the GCMCA delegated authority). If Board Procedures used
because of UOTH recommendation, only the CG can approve discharge, whether Honorable or
General, Under Honorable Conditions or Under Other Than Honorable (UOTH) Conditions.
NOTE: When the sole basis for separation is a serious offense which resulted in a conviction by
a court-martial which was authorized to, but did not impose a punitive discharge, (Bad-Conduct
Discharge or Dishonorable Discharge), the soldier's service may not be characterized Under
Other Than Honorable (UOTH) Conditions unless approved by the Secretary of the Army (3-8e).
Documents Required for Chapter:
( ) Request for separation
( ) Evidence of misconduct to include Summary Courts-Martial Result of Trial (DA Form 2329)
to include JAG Review Endorsement, Article 15's, bad check notification, letter of reprimand,
bar to reenlistment, DA Form 4187s for AWOL, etc.
( ) Medical examination
( ) Mental examination
( ) Debt avoidance counseling
( ) Education benefits counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
16
CHAPTER 15: DISCHARGE FOR HOMOSEXUAL CONDUCT
Before initiating any action regarding homosexuality, CONTACT YOUR TRIAL
COUNSEL!!!!
A soldier may be separated under this chapter if the soldier has engaged in, attempted to engage
in, or solicited another person to engage in a homosexual act or acts.
1-16 counseling Required: No (1-16a)
Medical Required: Yes (1-34a)
Mental Required: Yes (1-34b)
Approval Authority: Bde Cdr (1-21(3)(a))
Type of discharge authorized: Honorable or General, Under Honorable Conditions. A
discharge Under Other Than Honorable (UOTH) Conditions is authorized only if one of the
findings noted below exist.
Remarks: If service member waives board and general discharge is requested, Bde Cdr can
approve (1-21c(3)(4)).
NOTE: UP AR 635-200, paragraph 15-4a, when the sole basis for separation is homosexual
conduct, a discharge Under Other Than Honorable (UOTH) Conditions may be issued only if
there is a finding that, during the current term of service, the soldier attempted, solicited, or
committed a homosexual act:
1. By using force, coercion or intimidation.
2. With a person under 16 years of age.
3. With a subordinate in circumstances that violate customary military superior-subordinate
relationships.
4. Openly in public view.
5. For compensation.
6. Aboard a military vessel or aircraft.
Documents required for Chapter:
( ) A statement by the soldier that demonstrates a propensity or intent to engage in homosexual
acts. Soldiers are entitled to visit the Legal Assistance Office of the OSJA for guidance and
assistance before writing their statement.
OR
( ) Documentation showing that the soldier has engaged in homosexual acts. If a discharge
under UOTH Conditions is contemplated, include any evidence that will support 1 through 6
above.
( ) Medical examination
( ) Mental examination
( ) Debt avoidance counseling
( ) Education benefits counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
17
CHAPTER 18: FAILURE TO MEET BODY FAT STANDARDS
Soldiers who fail to meet the body fat standards set forth in AR 600-9 are subject to separation
UP of this chapter when such condition is the sole basis for the separation. Soldiers who have
been diagnosed by health care personnel as having a medical condition preventing them from
participating in the Army body fat reduction program will not be separated under this chapter.
IAW AR 600-9 and IAW AR 635-200, a commander may separate a soldier who is in the weight
control program under the following circumstances:
1. Failure to make satisfactory progress after any two consecutive monthly weigh-ins while
enrolled in the Army Weight Control Program (AR 600-9, para 21e(2)).
2. If no medical condition exists, initiation of separation proceedings is required for soldiers
who do not make satisfactory progress in the program after a period of 6 months, unless the
responsible commander chooses to impose a bar to reenlistment per AR 635-200, para 18-2a.
3. Initiation of separation proceedings is required for soldiers who fail to meet screening
table weight and body fat standards during the 12-month period following removal from the
weight control program, provided no medical condition exists (para 18-2a).
4. Soldiers without medical limitations who exceed the screening table weight and body fat
standards after the 12 month period but prior to 36 months following removal from the program,
and who do not meet the standards during the 90-day grace period prescribed by AR 600-9, will
be processed for separation.
1-16 counseling required: No (1-16a)
Medical required: Yes (1-34a)
Mental required: No (1-34b)
Approval Authority: Bn Cdr if notification procedure used otherwise Bde Cdr (1-21d)
Characterization of service: Honorable (18-2e).
REMARKS: Below is a proposed course of action for those commanders who identify a soldier
who is overweight:
1. Soldier is weighed and exceeds the screening table weight (pg 7, AR 600-9) and taped and
exceeds the body fat standard (pg 4, AR 600-9 as amended in IC 1, 4 Mar 94).
2. Commander initiates flag. The commander enrolls the soldier into the overweight program
and informs the soldier using a memorandum format. When the soldier acknowledges receipt of
the memorandum, the clock starts for the purposes of chapter action.
18
CHAPTER 18: FAILURE TO MEET BODY FAT STANDARDS
(Continued)
3. Commander refers the soldier to the nutritionist for nutritional counseling and proper weightloss counseling. This is done by memorandum and must take place as soon as the soldier is
enrolled in the program.
4. Commander refers the soldier to the TMC for medical screening to determine if there is a
medical condition that will preclude the soldier from losing weight. This is also done by
memorandum and also must take place as soon as possible after the soldier has been enrolled in
the program.
5. Conduct monthly weight-ins. If the soldier shows no improvement in any two consecutive
monthly weigh-ins, begin chapter. If after six months, the commander determines that the soldier
has not shown adequate improvement, the commander can either impose a bar to reenlistment or
can begin chapter.
6. If the soldier meets the body fat standard and the screening table weight table as prescribed
in AR 600-9, remove the soldier from the overweight program. This removal is accomplished
through a memorandum and should be kept on file in the unit for the next 36 months.
Documents Required for Chapter:
( ) Request for Separation
( ) Notification from immediate Commander and receipt of notification from Soldier
acknowledging entry into Weight Control Program (pg 8, AR 600-9). The clock starts ticking
upon receipt from the soldier.
( ) Memorandum from health care personnel indicating no medical condition exists which
precludes the soldier from losing weight (pg 9, AR 600-9). Completed and DATED.
( ) Memorandum from nutritionist indicating the soldier was provided nutrition education and
weight reduction counseling (pg 10, AR 600-9). Completed and DATED.
( ) If the chapter is for a soldier who re-enters the overweight program, evidence of prior
disenrollment from the weight control program, (complete prior weight control packet) (pg 10,
AR 600-9).
( ) Monthly weigh-in sheets (DA Form 5500-R for male and DA Form 5501-R for female)
( ) Medical examination
( ) Debt avoidance counseling
( ) Education benefits counseling
( ) ACAP Checklist
( ) DA Form 2-1 and ERB
( ) DA 268 - FLAG for elimination
19
REVOKING AN APPROVED CHAPTER THAT HAS BEEN SUSPENDED
A highly deserving soldier may be given a probation period to show successful rehabilitation
before the soldier's enlistment or obligated service expires. The separation authority may
suspend (except for action involving fraudulent enlistment or homosexuality) execution of an
approved separation for a period of full-time military duty not to exceed 6 months (para 1-20).
Upon satisfactory completion of the probation period or earlier, if rehabilitation has been
achieved, the authority that suspended the separation will cancel execution of the approved
separation. If the soldier engages in conduct similar to that for which separation was approved
but suspended, or otherwise fails to meet the appropriate standards of conduct and duty
performance, the separation authority will take the following actions:
1. Advise the soldier in writing that vacation action is being considered and the
reasons/evidence of misconduct that warrant such considerations.
2. Advise and give the soldier 3 duty days to consult with counsel and submit a written
statement in his or her own behalf or decline to make any statement.
3. The commander taking the action will consider any information the soldier submits. If the
soldier identifies specific legal issues for consideration, the separation authority will have the
matter reviewed by the unit trial counsel.
4. The separation authority may either:
(a) vacate suspension of the approved separation and execute the separation, or
(b) continue to suspend execution of the approved separation for the remainder of the
probation period.
20
APPENDIX A:
MEMORANDUM FOR: 108th Air Defense Artillery Legal Office
SUBJECT: Request for Preparation of Administrative Separation Packet
1. Request preparation of a separation packet on the following soldier:
____________________________
NAME (Last, First M.)
______________________
BASD
__________
RANK
_________________
ETS
______________________
SSN
______
SEX
_______________________________________
UNIT
2. All documentation is included to support separation under:
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
]
Chapter 5-3:
Chapter 5-8:
Chapter 5-11:
Chapter 5-13:
Chapter 5-16:
Chapter 5-17:
Chapter 6:
Chapter 7:
Chapter 8:
Chapter 9:
Chapter 11:
Chapter 13:
Chapter 14-5:
Chapter 14-12b:
Chapter 14-12c:
Chapter 15:
Chapter 18:
Secretarial Authority
Family Care Plan
Failure to Meet Procurement Medical Fitness Standards
Personality Disorder
School Drop
Other Designated Physical or Mental Condition
Dependency or Hardship
Fraudulent Enlistment
Pregnancy
ASAP Rehab Failure
Entry Level Status Performance and Conduct
Unsatisfactory Performance
Conviction by Civil Court
Pattern of Misconduct
Commission of a Serious Offense
Homosexual Conduct
Failure to Meet Body Fat Standards
3. Recommend that the soldier receive:
[ ] an Honorable
[ ] a General
4. The soldier [
] (is)
[
] an Under Other Than Honorable Conditions Discharge
[ ] (is not) pending Medical Evaluation Board.
5. Point of Contact for this action is ________________________ Phone ____________________.
___________________________
___________________________
_______, _____
[ ] Commanding [ ] Acting Commander
21
DEVELOPMENTAL COUNSELING FORM
For use of this form see FM 22-100.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)
PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates.
ROUTINE USES: For subordinate leader development IAW FM 22-100. Leaders should use this form as necessary.
DISCLOSURE: Disclosure is voluntary.
PART I – ADMINISTRATIVE DATA
Rank / Grade
Social Security No.
Name (Last, First, MI)
Organization
Date of Counseling
Name and Title of Counselor
PART II - BACKGROUND INFORMATION
Purpose of Counseling: (Leader states the reason for the counseling, e.g. Performance/Professional or Event-Oriented
counseling and includes the leaders facts and observations prior to the counseling):
Event Oriented Counseling
PART III - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to counseling.
Key Points of Discussion:
You are hereby counseled for the above indicated misconduct and/or unsatisfactory duty performance in accordance with
AR 635-200, para 1-16. Continued behavior of this kind may result in initiation of separation action to eliminate you
from the Army. If you are separated for unsatisfactory performance, you could receive an Honorable or General
Discharge. If you are separated for misconduct, you could receive an Honorable, General, or Other Than Honorable
(OTH) Discharge. A General or OTH Discharge could severely prejudice you in civilian life. Additionally, an OTH
Discharge could deprive you of many or all military and veteran’s benefits. Any further act of misconduct or
unsatisfactory performance may cause you to be eliminated without further counseling.
OTHER INSTRUCTIONS
This form will be destroyed upon: reassignment (other than rehabilitative transfers), separation at ETS, or upon retirement. For separation requirements
and notification of loss of benefits/consequences see local directives and AR 635-200.
22
APPENDIX C
MEMORANDUM FOR Commander, 126th Finance Battalion, ATTN: AFZA-SG-FO, Fort Bragg,
North Carolina 28310-5000
SUBJECT: Debt Avoidance Notice
1. The soldier listed below is being considered for early separation from the Army. Request you review the
individual’s pay account and you debt management records to determine any outstanding indebtedness to the U.S.
Government:
Name: ____________________________ Rank: ___________
SSN: _______________________ Pending Chapter Action: ____________________
Estimated Date of Separation: ___________________________
2. If the individual is indebted to the U.S. Government, I request appropriate action be taken to satisfy the
indebtedness.
3. Request a reply with the results of your financial review.
______________________________
(Signature of Commander)
Statement of Understanding
I am aware that:
1. If I am indebted to the U.S. Government, my pay and allowances will be held and my pay option will stop (i.e.,
Direct Deposit). I am also aware that my allotments will stop with the exception of involuntary support
(garnishment), child support, and insurance allotments.
2. While my pay is held I may request payment of my end-of-month pay my submitting a DA Form 2142, signed by
my commander, to Finance along with a memorandum stating that I have at least 30 days until separation. I also
realize that I will receive no payments within 30 days of my estimated date of discharge (all monies due will be paid
upon separation).
3. If my pending separation action is disapproved or discontinued, and my pay is held, I realize that my commander
must notify Finance to reestablish my pay option.
______________________________
(Signature of Soldier & Date)
23
APPENDIX D
MEMORANDUM FOR: Commander, (company, battalion) Fort Bragg, North Carolina 28310-5000
SUBJECT: Pre-Separation Counseling on Educational Benefits
In accordance with 10 USC 1142 (Pre-Separation Counseling), I have received counseling on Veteran’s Educational
Benefits. I understand that I must receive a fully Honorable Discharge (DD Form 256A) and meet minimum time-inservice requirements to be eligible to receive benefits. Also, I understand the Veteran’s Administration (VA)
determines eligibility for benefits and dollar amounts. The VA toll free telephone number is 1-800-827-1000.
______________________________________
(Signature of Soldier and Date)
_______________________________________
(Signature of Education Counselor)
24
FAMILY CAREPLAN COUNSELINGCHECKLIST
For use of this form, seeAR 600-20; theproponent agency is ODCSPER
AUTHORITY:
PRIVACYACT STATEMENT
10 U.S.C. Section 3013, Secretary of theArmy: Army Regulation 600-20, Army Command Policy andE.O
9397 (SSN).
PRINCIPALPURPOSE:
Toemphasize tosoldiers thesignificance of their responsibilities tothemilitary serviceand their family
members whileperformingrequired military duties.
ROUTINE USES:
DISCLOSURE:
None.
Mandatory; Failuretomaintain aFamily CarePlan couldsubject thesoldier to separation, administrative
UCMJ.
action, or disciplinary actionunder the
Careful planning is requiredtoensure adequate care of family members whileperforming requiredmilitary duties. Pregnant
soldiers, single parents, anddual-military couples
with family members will be counseled in accordance with AR600-20. The
soldier and the commanding officer (or designated representative) will initial each item on the
checklist.
PARTI - ACTIVEARMYAND RESERVECOMPONENT
SOLDIER
COMMANDER
A. I am receivingFamily Care Plan counseling by my commander (or designatedrepresentative)
because my current family status is:
1.
A pregnant soldier who:
a. Has no spouse; is divorced; widowed, or separated; or is residing without her spouse.
b. Is marriedto another servicemember of AC or RC of any service (Army, Air Force, Navy, Marines, Coast Guard).
2. A soldier who has no spouse; is divorced, widowed, or separated or is residing apart from his/her spouse; who has joint or full legal and physical
custody of one or morefamily members under age18 or whohas adult family members incapable of self-careregardless of age.
3. A soldier who is divorced (not remarried) and who has liberal or extendedvisitation rights by court decreewhich would allow family members to
be solely inthesoldier's carein excess of 30consecutive days.
4. A soldier whose spouse is incapable of self-care or is otherwise physically, mentally, or emotionally disabled so as to require special care or
assistance.
5. A soldier categorized as half of a dual-military couple of the AC or RC of any service (Army, Air Force, Navy, Marines, Coast Guard) who has joint
or full legal custody of one or more family members under age 18or who has adult family members incapable of self-careregardless of age.
B. I understand that I must arrange for thecareof my family member(s) so as to be:
(1) Available for duty when and where the needs of the Army dictate; (2) Able to perform my assigned military duties without interference of family
responsibilities.
C. I have beencounseled onthe importanceof:
1. Selecting qualified, reliable, andstable guardians (temporary andlong-term), whom I wouldhave no reservations about entrusting thesole care of
my family members, and who are both capableand willing tocarefor them in my absence.
2. Providing maximum information to guardians on the full extent of their responsibilities and on procedures for gaining access to military/civilian
facilities, services, entitlements and benefits on behalf of my family member(s).
3. Providing all necessary documentation and financial support so that the designated guardians have everything necessary to act in that capacity.
D. I understand that designated guardians must be able to assumeresponsibility for my family member(s) during any periods of absence toinclude: during
duty hours, alerts, field duty, roster duty, TDY, deployments, AT, MUTAs, ADT, or in the event of hospitalization, or other periods of absence for military
duty, emergencies or unexpected circumstances.
E. I understand that I am fully responsible for making all necessary arrangements (housing, educational, legal, transportation, financial, religious, special,
etc.) to ensurea smooth, rapid turnover of family member care responsibilities in case the plan is implemented.
F. I understand that I must initiate legal documentationsuchas thepower of attorney for guardianship (DA Form5841-R) which will authorize guardian(s)
to act in locoparentis; to performany andall acts as fully toall intents and purposes as I might or could if personally present; to authorize for the care and
treatment of my family member(s) regardless of whether onan emergency basis, or for routinecare, includingall major surgery deemednecessary by aduly
licensed staff physician at any military or civilianhospital; toregister my child(ren) in school, andto grant or to withholdpermissions as my attorney shall
deem appropriate.
G. I understandthat designatedguardians must submit notarized certificates of acceptance(DA Form 5840-R)
agreeing toaccept full responsibility for my family member (s); attesting that they havereceivedall necessary and essential documents; andattesting tothe
fact that they have been providedinformationon how to gain access to military/civilian facilities, services, entitlements and benefits on behalf of my family
member (s).
DA FORM 5304-R, APR 1999
DA FORM 5304-R, MAR 92 ISOBSOLETE
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25
PART I - ACTIVEARMYAND RESERVECOMPONENT (Continued)
SOLDIER
COMMANDER
H. I understand that I must maintain in my Family Care Plan, a DD Form 1172 for each family member to ensure the issue/renewal of Uniformed Services
Identification Cards inmy absence.
I. I understand that my Family CarePlan must be updated and recertifiedby my commander at least annually (moreoftenif requiredby my commander or
missionof my unit), or in the event of any change inmy family status, guardians, legal custody, duty station, etc.
J. I understand that it is strongly encouraged (though not mandatory) that I ensure that I have an updated will which specifies my desires concerning
custody of my family member (s) in theevent of my death.
K. I understand that therearevoluntary and involuntary procedures for my separationfrommilitary service when my parental responsibilities interferewith
the performanceof my military duties.
L. I understand that I will receive no special consideration in duty assignments or duty stations based on my responsibility for my family member(s) unless
enrolled intheExceptional Family Member Program (EFMP) in accordance with AR 608-75.
M. I understand that I am fully responsible for all transportation arrangements and costs pertaining to transportation of family member(s) to guardian or
guardian todependent family member (s).
N. If I am assignedOCONUS, I understand that I must identify an escort for my family member (s) in the event that Noncombatant EvacuationOperations
(NEO) areput into effect.
O. If NEO procedures are not initiated at the time I am required to implement my Family Care Plan, I understand that I may request the opportunity to
personally escort my family membe r(s) back to CONUS if time and the nature of the military situation permits, and my commander approves. I also
understand that I may request approval for the designatedguardian toreside in my government quarters inmy absence. I further understand that the Army
will not be responsible for reimbursement of any travel costs incurred by the guardian or escort unless they are otherwise eligible under their own military
family member status.
P. I understand that members of a dual-military couple may submit the same basic Family Care Plan to both commanders, provided that neither military
member is identified as the long-term guardian inthe plan. Theoriginal Family CarePlan will bemaintained by the commander of themilitary member least
likely to deploy, with acopy of theDA Form 5305-R forwardedto the spouse's commander. If bothmilitary members are equally likely to deploy, the original
will be filed with the Army member's commander and a copy with the commander of the other service. If both are Army members and equally likely to
deploy, it is inconsequential which commander has theoriginal, so long as both commanders have copies in the unit files.
Q. I understand that I should provide letters of instruction outlining all special arrangements and instructions the guardians or escort should be aware of
(See Figure 5-4, AR 600-20).
R. I have received copies of all the required forms and documentation, and know whom to contact in the event I have additional questions or need additional
assistance inpreparingtheFamily Care Plan.
S. I understand that I must submit the complete Family Care Plan with all attendant documents to my commander within the time limits specified by my
commander (or designatedrepresentative):
AA 30 days from date of this counseling session.
RC 60 days fromdateof this counselingsession.
T. I understandthat it is my responsibility to notify my commander in advance if I amawareof any circumstances beyond my control that might prevent me
from meeting thesubmission deadlines. The commander is authorized togrant a one-time extension of 30 days based on extenuating circumstances.
PARTII - ACTIVE ARMY AND RCSERVING ONACTIVE DUTY
Policies, Provisions, Entitlements, Benefits, and Services:
A. Policies governing deletion or deferment from assignment instructions because of personal reasons. See Chapter 3, AR 614-200 (AA enlisted) or
Chapter 6, AR 614-100 (AA officers) or AR 135-91 (RC).
B. Policies governing reassignment eligibility. All soldiers areexpected to serve CONUSandOCONUStours (including unaccompaniedtours). The needs of
the Service provide the basis for selecting a soldier for reassignment in accordancewith AR 614-30, AR614-200, and AR 614-100.
C. Entitlements toassignment of government or pay of basic allowances for quarters. SeeChapter 10, AR 210-50.
D. Policies governing entitlement to basic allowance for subsistence, application procedures, and payment. These are contained in Chapter 1, part 3, AR
37-104-3; and Chapter 20, DoD Military Pay and Allowances Entitlements Manual.
E. Provisions for applying for concurrent travel of family members when alerted for overseas movement Approved joint domicile assignments do not
constitute authority to move family members to the overseas command at government expense. Application for family member travel must be made in
accordance with AR 55-46.
PAGE2, DA FORM 5304-R, APR1999
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26
PARTII - ACTIVEARMY
SOLDIER
COMMANDER
F. Eligibility requirements for shipment of household goods to the next permanent duty stationat government expense. See Chapter 4, AR55-71and Part D,
Chapter 5, Volume 1, Joint Federal Travel Regulation (JFTR).
G. The entitlement to government paid transportation of family members to the next permanent duty station. SeeChapter 9, AR 37-106 and Part C, JFTR.
Transportationallowances for dependent family member movement will be paid for under thefollowingconditions:
1.
2.
If traveling in a PCS status between CONUSpermanent duty stations. However, family members are not authorized to move to or from TDY
stations at government expense.
If traveling to, from, or between OCONUSduty stations in PCSstatus provided tour length requirements have been satisfied. See Section III,
Chapter 1, AR 55-46 regarding tour lengthrequirements to qualify for family member movement to, fromandbetween overseas areas.
H. The status of noncommand sponsored family members in the overseas command. Seeparagraph 1-17, AR 55-46.
I. Services provided by theArmy Community Services (ACS) regardingfinancial planning. Seechapter 9, AR 608-1.
J. Services available from Personal AssistancePoints at major points of embarkation in the CONUS.
K. Maternity counselingfor pregnant singlesoldiers on the costs of child bearingand raising.
L. Provisions of CHAMPUS.
PARTIII - MILITARYSPOUSE ANDSPOUSE'S COMMANDERCERTIFICATION
A. Military spouse: Wehavebeencounseled onour responsibilities tothe military serviceandour family member (s.)
1. SIGNATUREOFSPOUSE
2. DATE (YYYY/MM/DD)
3. TYPEDORPRINTEDNAMEOFSPOUSE
B.
4. SSN
Spouse'scommander: I haveprovidedcounseling for themilitary spouseassignedto my unit concerning Family CarePlanrequirements.
1. SIGNATUREOFSPOUSE'S COMMANDER
2. DATE
(YYYY/MM/DD)
3a. UNIT ADDRESS
4. TYPEDORPRINTEDNAMEOFSPOUSE'S COMMANDER
b. E-MAIL ADDRESS
PARTIV- SOLDIERANDCOMMANDERCERTIFICATION
A. Soldier: I havebeencounseledonmy responsibilities to theArmy andto my family member(s).
1. SIGNATUREOFSOLDIER
2. DATE
(YYYY/MM/DD)
3. TYPEDORPRINTEDNAMEOFSOLDIER
4. SSN
B. Soldier'scommander: I haveprovidedcounseling tothesoldier onhis/her responsibilities to the military serviceand tohis/her family member(s).
1. SIGNATUREOFSOLDIER'S COMMANDER
2. DATE
(YYYY/MM/DD)
3a. UNITEDADDRESS
4. TYPEDORPRINTEDNAMEOFSOLDIER'S COMMANDER
b. E-MAIL ADDRESS
PAGE3, DA FORM 5304-R, APR1999
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FAMILY CAREPLAN
For use of this form, see AR 600-20; the proponent agency is DCSPER
PRIVACYACT STATEMENT
AUTHORITY:
10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy and E.O. 9397 (SSN)
PRINCIPAL PURPOSE:
To emphasize to soldiers the significance of their responsibilities tothemilitary serviceandtheir family members whileperforming requiredmilitary duties.
None
ROUTINEUSES:
Mandatory; Failure tomaintain aFamily Care Plan could subject thesoldier to separation, administrative action, or disciplinary actionunder theUCMJ.
DISCLOSURE:
PART I - SOLDIER'S FAMILY CARE
A.
I was counseled on
(date) , and fully understand the policy on family member
care responsibilities. I understand that I must arrange for care of my family members, remain available for deployment and training, and report for duty as required without
interference of responsibility for family members. I assume responsibility for all obligations for such things as child care, food, adequate housing, transportation, and
emergency needs of my family members regardless of age.
B.
I have madeand will maintain arrangements for the care of my family members during all thefollowing:
1.
Duty
6.
Temporary Duty
2.
Exercises/fieldduty
7.
Unit Training Assembly
3.
Permanent Change of Station
8.
Active Duty Training
4.
Alerts
9.
Unaccompanied Tours
5.
Annual Training
10. Mobilization
C.
11.
12.
13.
14.
INITIALS
Deployment
Other Military Duty
Emergencies
Leave/non-duty Time
I understand the importance of ensuring the proper care for my family members, and ensuring my own readiness and deployability as well. I further understand that in light of
the critical natureof boththese requirements:
1.
Failure to make and maintain adequate family member carearrangements inaccordancewiththeArmy's policy is grounds for disciplinary action or separation.
2.
Nonavailability for worldwideassignment and/or unit deployment may lead to my separationfromtheArmy.
3.
If arrangements for the care of my family members fail to work, I amnot automatically excused fromprescribed duties, unit deployment, or reassignment.
4.
If I fail to maintain a Family Care Plan or provide false information regarding my plan, I am subject to separation, administrative action, or disciplinary action under
UCMJ.
5.
I must maintain an up-to-date Family Care Plan and revise my Planwhen circumstances change. I understand that Family Care Plans may betestedat thediscretion of
the commander.
6.
I will receive no special consideration in duty assignments or duty stations based on my responsibilities for my family members unless enrolled in the
Exceptional Family Member Program (EFMP) in accordancewith AR 600-75.
D.
I have made all necessary arrangements (legal, educational, financial, religious, special, etc.) to ensure asmooth, rapidturnover of family member careresponsibilities incase
this planis implemented.
E.
I have arranged for necessary travel required to transfer my family members to a designated person. If my principal designee is not in the local area, I havearrangedwith a
nonmilitary person in the local areatoassume temporary guardianship of my family members until they are transferred tomy principal care designee, or that designee arrives to
assume responsibility for their care.
F.
A copy of DA Form 5841-R (Power of Attorney) or equivalent documents and a copy of DA Form 5840-R (Certificate of Acceptance as Guardian) for each
escort or guardian whether temporary or long-termis attached tothis plan.
G.
The following additional required documents are completed, included inthis plan, andwill be put into effect as part of my Family CarePlan.
1. DD Form 1172 (Application for UniformedServices IdentificationCard) for eachfamily member whether they have a currently validID card or not.
2. DD Form 2558 (Authorization to Start, Stop or Change an Allotment for Active Duty or Retired Personnel) or other proof of financial support for expenses incurred by
guardianandfamily members.
3. Copies of Letters of Instruction (which have been forwarded to designated escorts or guardians alongwithpowers of attorney and other pertinent documents), outlining all
special instructions concerning the careof my family members have also beenincludedinmy Family Care Plan.
H.
I have thoroughly briefed escorts and guardians on the full extent of their responsibilities and on procedures for gaining access to military/civilian facilities, services,
entitlements andbenefits onbehalf of my family members.
I.
I am confident that my Family Care Plan is workable, andto the best of my knowledge, the guardian
designated will be both willingand able to carry out theresponsibilities of caring for my family members.
A.
I (We) have designated thefollowingtemporary guardianto care for my (our)family member (s)until responsibility is transferredto escort or principal (long-term)guardian.
1.
TYPED OR PRINTED NAME
3.
TELEPHONENUMBER (Include AreaCode)
(s)
and escort
(s)
I have
PART II - DESIGNATION OF GUARDIANS/ESCORTS
2a.
COMPLETEADDRESS (Including Street, Apartment Number,
P.O. Box Number, Rural Route Number, City, State, and ZIP+ 4 where applicable)
2b. E- MAIL ADDRESS
DA FORM 5305-R, APR 1999
DA FORM 5305-R, MAR 1992 ISOBSOLETE
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28
B.
I (We) havedesignated the following individual(s) as principal long-termguardian(s) for my(our) family member(s). The designated guardian(s)residein thecontinental United States or UnitedStates
territories.
1.
TYPED OR PRINTED NAME
3.
TELEPHONENUMBER (Include AreaCode)
C.
I (We) have designated thefollowingindividual(s)as escort for my(our) family member(s) if evacuation from OCONUSbecomes necessary (applies only topersons assigned OCONUS):
1.
TYPED OR PRINTED NAME
3.
TELEPHONENUMBER (Include AreaCode)
2a.
COMPLETEADDRESS (Including Street, Apartment Number,
P.O. Box Number, Rural Route Number, City, State, and ZIP+ 4
where applicable)
2b. E-MAIL ADDRESS
2a.
COMPLETEADDRESS (Including Street, Apartment Number,
P.O. Box Number, Rural Route Number, City, State, and ZIP+ 4
where applicable)
2b. E-MAIL ADDRESS
PART III - DUAL MILITARY COUPLES ONLY
MILITARY SPOUSE ANDCOMMANDERCERTIFICATION
A.
Spouse: We have made arrangements and will maintain arrangements for thecareof our family member(s)inall circumstances required by our commitment tothemilitary andour family.
1.
SIGNATUREOF SPOUSE
3.
TYPED OR PRINTED NAMEOF SPOUSE
5.
Recertification
B.
Commander: I have counseled the military spouse assigned tomy unit, reviewed the Family Care Plan, and I am satisfied that the members havemadeadequatefamily care arrangements.
1.
SIGNATUREOF COMMANDER
4.
TYPED OR PRINTED NAMEOF COMMANDER
5.
Recertification
A.
Soldier: I (We) have made arrangements and will maintain arrangements for the care of my(our) family member(s) in all circumstances required by my(our) commitment to the military and my(our)
family.
1.
SIGNATUREOF SOLDIER
3.
TYPED OR PRINTED NAMEOF SOLDIER
5.
Recertification
B.
Commander: I have reviewed the Family Care Plan, and I am satisfied that the members have made adequate family care arrangements that will allow for a full range of military duties and for
worldwideavailability as definedhere.
1.
SIGNATUREOF COMMANDER
4.
TYPED OR PRINTED NAMEOF COMMANDER
5.
Recertification
2.
a. INIT.
a. INIT.
DATE
4.
b. INIT.
2.
DATE
b. INIT.
c. INIT.
DATE
c. INIT.
DATE
SSN
d. INIT.
DATE
3.
DATE
DATE (YYYY/MM/DD)
e. INIT.
DATE
DATE
UNIT ADDRESS
d. INIT.
DATE
e. INIT.
DATE
DATE
PART IV - SOLDIERAND COMMANDERCERTIFICATION
a. INIT.
a. INIT.
2.
DATE
4.
b. INIT.
2.
DATE
REVERSEOF DAFORM 5305-R, APR1999
b. INIT.
c. INIT.
DATE
DATE
c. INIT.
SSN
DATE
3.
DATE
DATE (YYYY/MM/DD)
d. INIT.
DATE
e. INIT.
DATE
UNIT ADDRESS
DATE
d. INIT.
DATE
e. INIT.
DATE
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APPENDIX F
Pregnancy Counseling Checklist
(AR 635-200, Figure 8-1)
Notice: Required by the Privacy Act of 1974 (5 U.S.C. 552a). Prior to soliciting any personal information in the
course of counseling a soldier, the counselor (see para 8-6) will advise the soldier substantially as follows:
In the course of counseling you concerning the decisions you will have to make in connection with your
pregnancy, I will request certain personal information from you. My only purpose in requesting this information is
to assist you in planning how to meet your responsibilities to the child and to the military, and to determine if there is
anything that I or the Army can do to assist you in meeting those responsibilities. Disclosure of your SSN and other
personal information is voluntary. You are not required to provide personal information to me, but Army regulations
do require that you complete a Statement of Counseling. If you choose not to provide personal information to me,
however, I may not be able to effectively assist you. No use of the information will be made outside the Department
of Defense. A copy of the Statement of Counseling will be maintained in your MPRJ until this action is completed,
at which time it will be destroyed. My authority for requesting this information is Section 3013, Title 10, United
States Code.
The purpose of this counseling is to inform you of the options, entitlements, and responsibilities in
connection with your pregnancy.
Information on your entitlements:
a. Retention or separation:
(1) You may request separation or elect to remain on active duty.
(2) For more information, see paragraph 8-9.
b. Maternity care:
(1) If you remain on active duty you will receive treatment in a military facility or in a civilian facility, if there is
no military maternity care available within 30 miles of your location. If you separate, you are authorized treatment
only in a military facility that has maternity care. You are NOT authorized care in a civilian facility at Government
expense.
(2) For more information, see AR 4O-3, paragraph 2-35 for care while on active duty; AR 40-3, paragraph 4-44,
for care after separation.
c. Leave:
(1) You may request ordinary, advance, and excess leave in order to return home, or other appropriate place, for
the birth of your child or to receive other maternity care. Such leave usually terminates with onset of labor.
(2) Nonchargeable convalescent leave for postpartum care is limited to the amount of time essential to meet your
medical needs.
(3) For more information, see AR 630-5, chapter 9, section II.
d. Maternity clothing and uniforms:
(1) Military maternity uniforms will be provided to soldiers.
«CoOfficeSymbol»
30
(2) For more information, see AR 670-1, chapter 4.
e. BAQ and Government quarters:
(1) Availability depends on the status of quarters at your installation.
(2) For more information, see Post Housing Office.
f. Assignments:
(1) You will not normally receive PCS orders directing movement overseas during your pregnancy. However,
you will be considered available for unrestricted worldwide assignment upon completion of postpartum care.
(2) For more information, see AR 614-30, paragraph 3-3.
g. Separation for unsatisfactory performance, misconduct, or parenthood:
(1) If your performance or conduct warrant separation for unsatisfactory performance or misconduct, or if
parenthood interferes with your duty performance, you may be separated involuntarily even though you are pregnant.
(2) For more information, see paragraph 5-8 and chapters11, 13, and 14.
h. Family care counseling:
(1) You must have an approved family care plan on file stating actions to be taken in the event you are assigned
to an area where dependents are not authorized or you are absent from your home on military duty. Failure to
develop an approved care plan will result in a bar to reenlistment.
(2) For more information, see Post Housing Office.
______________________________________________________________________________
Should you desire assistance in gathering additional Information on the above subjects, I will assist you in locating
the appropriate information. Further, if you desire, I will assist you in contacting the American Red Cross or other
appropriate agencies.
31
AFZA-AS-S__-__
MEMORANDUM FOR Commander, unit, Fort Bragg, North Carolina
SUBJECT: Pregnancy Counseling
I affirm that I have been counseled by CPT ____________ this date on all items on the attached counseling
checklist, and I understand my entitlements and responsibilities. I understand that if I elect separation, I may receive
maternity care at Department of Defense expense, on a space available basis for up to 6 weeks postpartum for the
birth of my child only in a military medical treatment facility which has maternity care capability and that I may elect
a separation date no later than 30 days prior to expected date of delivery or latest date my physician will authorize
me travel, whichever is earlier. Further, I understand that many military medical treatment facilities cannot provide
maternity care and that unforeseen circumstances or medical emergency could force me to use civilian medical
treatment facilities following separation from active duty. Should this happen, I fully understand that UNDER NO
CIRCUMSTANCES can TRICARE, any military department, or the Veterans Affairs reimburse my civilian
maternity care expenses. Such costs will be a matter of my personal responsibility. Further, I understand that the
separation authority, in conjunction with my military physician based on the needs of the Army, will determine my
separation date. I also understand that if I should remain on active duty, I will be expected to fulfill the terms of my
enlistment contract. If I elect to remain on active duty, I understand that I must remain available for unrestricted
service on a worldwide basis when directed and that I will be afforded no special consideration in duty assignments
or duty stations based on my status as a parent.
SOLDIER’S NAME
RANK, U.S. Army
SSN
32
AFZA-AS-S__-__
MEMORANDUM FOR _________, unit, Fort Bragg, North Carolina 28310-5000
SUBJECT: Pregnancy Counseling
Request your election of appropriate option indicated below and return within _____ days.
COMMANDER’S NAME
CPT, AD
Commanding
_____ During the counseling session there was no coercion on the part of the counselor influencing my decision.
_____ I elect separation for reason of pregnancy per AR 635-200, chapter 8. I desire to remain on active duty until
__________________________. (In no case later than 30 days prior to expected date of delivery.)
_____ I elect to remain on active duty to fulfill the terms of my enlistment contract.
SOLDIER’S NAME
RANK, U.S. Army
SSN
APPENDIX G
33
DATE:____________
MEMORANDUM FOR
SUBJECT: Enrollment in Body Fat Reduction Program
1. You have been determined to exceed applicable body fat standards. In accordance with AR 600-9, you are
enrolled in a body fat reduction program and flagged under the provisions of AR 600-8-2.
2. You will be weighed and taped on a monthly basis. A goal of 3-8 pounds of weight loss per month is deemed to
be satisfactory progress. Failure to make satisfactory progress in any two consecutive months could result in you
involuntary separation from the Army under the provisions of AR 635-200, Chapter 18. If you are still overweight
and have failed to achieve the body fat standard six months from this date, depending on your progress, I will initiate
elimination or impose bar to reenlistment.
_____________________________________
(Signature of Commander & Date)
I understand my responsibilities to achieve the body fat standards and to have my weight recorded on a monthly
basis.
_____________________________________
(Signature of Soldier & Date)
______________
(Date)
34
MEMORANDUM FOR Medical Officer
SUBJECT: Medical Screening for Body Fat Reduction Program
1.______________________________ exceeds the height for weight tables by _______ pounds and exceeds the
body fat standards by _______ percent.
2. I request that you conduct a medical evaluation to determine if the soldier’s overweight status is the result of a
medical condition.
______________________________________
(Signature of Commander & Date)
RESULT OF MEDICAL SCREENING FOR BODY FAT REDUCTION PROGRAM
1.____________________________ has been examined and determined to be (fit) (unfit) to participate in a body fat
reduction/exercise program.
2. The cause of the overweight condition (is) (is not) due to a medical condition.
3. The following action is recommended:
_________ Body fat reduction/ exercise program
_________ Medical treatment for a pathological medical disorder.
________________________________________
(Signature of Medical Officer & Date)
____________
(Date)
35
MEMORANDUM FOR Medical Officer/Nutritionist
SUBJECT: Nutritional Counseling
1.____________________________ exceeds the height for weight tables by _______ pounds and exceeds the body
fat standards by _______ percent.
2. I request that you provide the soldier nutritional counseling to assist participation in a body fat reduction program.
____________________________________
(Signature of Commander & Date)
CERTIFICATION OF NUTRITIONAL COUNSELING
1. _____________________________ has been provided nutritional counseling to assist participation in the body
fat reduction program.
2. Follow-up counseling should be prodided at the unit level using information in Appendix C of AR 600-9 and
with the assistance of your unit Master Fitness Trainer.
_______________________________________
(Signature of Medical Officer/Nutritionist & Date)
APPENDIX H
36
Circletheappropriate copy designator
Copy 2
Copy 3
Copy 1
Copy 4
PERSONNELACTION
For useof this form, see AR600-8-6 and DAPAM600-8-21; the proponent agency is ODCSPER
DATAREQUIREDBY THEPRIVACY ACTOF1974
AUTHORITY:
PRINCIPALPURPOSE:
Title5, Section3012; Title 10, USC, E.O. 9397.
Usedby soldier inaccordancewith DAPAM600-8-21 when requesting apersonnel actiononhis/her ownbehalf
(Section III).
ROUTINEUSES:
Toinitiatetheprocessing of apersonnel actionbeing requestedby thesoldier.
DISCLOSURE:
Voluntary. Failureto providesocial security number may result in adelay or error in processingof therequest for
personnel action.
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
3. FROM (Include ZIP Code)
BATTALION ADDRESS
HQDA (TAPC-PDT-S)
2461 Eisenhower Ave.
Alexandria, VA 22331-0479
COMPANY ADDRESS
SECTIONI - PERSONALIDENTIFICATION
4. NAME (Last, First, MI)
5. GRADEORRANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
SECTIONII - DUTY STATUS CHANGE (AR600-8-6)
7. Theabovesoldier's duty status is changed from
to
effective
hours,
SECTIONIII - REQUEST FORPERSONNELACTION
8. I request the followingaction: (Check as appropriate)
ServiceSchool (Enl only)
Special Forces Training/Assignment
IdentificationCard
ROTCor ReserveComponent Duty
On-the-JobTraining (Enl only)
Identification Tags
VolunteeringFor OverseaService
RetestinginArmy Personnel Tests
Separate Rations
Ranger Training
Reassignment MarriedArmy Couples
Leave- Excess/Advance/OutsideCONUS
Reassignment ExtremeFamily Problems
Reclassification
Change of Name/SSN/DOB
Officer CandidateSchool
Other (Specify)
Exchange Reassignment
(Enl only)
Airborne Training
Asgmt of Pers with Exceptional Family Members
9. SIGNATUREOFSOLDIER (When required)
10. DATE (YYYYMMDD)
SECTIONIV - REMARKS (Applies toSections II, III, and V) (Continue on separate sheet)
I request voluntary seoaration UP AR 635-200, paragraph 5-3, under Secritarial Plenary Authority. The basis for this is
___________. No other provision in the regulation applies, and early separation is clearly in the best intrest of the Army. I
request a separation date of ______________. I understand that if I have not completed my statutory servie obligation (10 USC
651), I may be transferred to the Individual Ready Reserve (IRR).
3 Encls
1. Request for separation
2. Education Counseling
3. ERB & 2-1
4. ACAP Checklist
SECTIONV - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that therequest for personnel action (SectionIII) containedhereinHASBEEN VERIFIED
RECOMMENDAPPROVAL
12. COMMANDER/AUTHORIZEDREPRESENTATIVE
DA FORM 4187, JAN 2000
RECOMMENDDISAPPROVAL
13. SIGNATURE
PREVIOUS EDITIONS AREOBSOLETE
ISAPPROVED
ISDISAPPROVED
14. DATE (YYYYMMDD)
USAPA V1.00
APPENDIX I
37
Circletheappropriate copy designator
Copy 2
Copy 3
Copy 1
Copy 4
PERSONNELACTION
For useof this form, see AR600-8-6 and DAPAM600-8-21; the proponent agency is ODCSPER
DATAREQUIREDBY THEPRIVACY ACTOF1974
AUTHORITY:
PRINCIPALPURPOSE:
Title5, Section3012; Title 10, USC, E.O. 9397.
Usedby soldier inaccordancewith DAPAM600-8-21 when requesting apersonnel actiononhis/her ownbehalf
(Section III).
ROUTINEUSES:
Toinitiatetheprocessing of apersonnel actionbeing requestedby thesoldier.
DISCLOSURE:
Voluntary. Failureto providesocial security number may result in adelay or error in processingof therequest for
personnel action.
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
3. FROM (Include ZIP Code)
BATTALION ADDRESS
Headquarters
35th Sig Bde (Corps) (Airborne)
Fort Bragg, North Carolina 28310
COMPANY ADDRESS
SECTIONI - PERSONALIDENTIFICATION
4. NAME (Last, First, MI)
5. GRADEORRANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
SECTIONII - DUTY STATUS CHANGE (AR600-8-6)
7. Theabovesoldier's duty status is changed from
to
effective
hours,
SECTIONIII - REQUEST FORPERSONNELACTION
8. I request the followingaction: (Check as appropriate)
ServiceSchool (Enl only)
Special Forces Training/Assignment
IdentificationCard
ROTCor ReserveComponent Duty
On-the-JobTraining (Enl only)
Identification Tags
VolunteeringFor OverseaService
RetestinginArmy Personnel Tests
Separate Rations
Ranger Training
Reassignment MarriedArmy Couples
Leave- Excess/Advance/OutsideCONUS
Reassignment ExtremeFamily Problems
Reclassification
Change of Name/SSN/DOB
Officer CandidateSchool
Other (Specify)
Exchange Reassignment
(Enl only)
Airborne Training
Asgmt of Pers with Exceptional Family Members
9. SIGNATUREOFSOLDIER (When required)
10. DATE (YYYYMMDD)
SECTIONIV - REMARKS (Applies toSections II, III, and V) (Continue on separate sheet)
I request voluntary seoaration UP AR 635-200, paragraph 6-3a, for dependancy. I am not under charges, in confinement,
under investigation, or pending consideration for separation per AR 635-40, Ar 604-10, Chapters 9, 11, 13, 14, or paragraph 5-8.
I request a separation date of ______________. I understand that if I have not completed my statutory servie obligation (10 USC
651), I may be transferred to the Individual Ready Reserve (IRR).
__
1.
2.
3.
4.
5.
6.
7.
Encls
Request for separation
Statement by / on behalf of dependant
Statement from __________
Statement from __________
Education Counseling
ERB & 2-1
ACAP Checklist
SECTIONV - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that therequest for personnel action (SectionIII) containedhereinHASBEEN VERIFIED
RECOMMENDAPPROVAL
12. COMMANDER/AUTHORIZEDREPRESENTATIVE
DA FORM 4187, JAN 2000
RECOMMENDDISAPPROVAL
13. SIGNATURE
PREVIOUS EDITIONS AREOBSOLETE
ISAPPROVED
ISDISAPPROVED
14. DATE (YYYYMMDD)
USAPA V1.00
APPENDIX J
38
Circletheappropriate copy designator
Copy 2
Copy 3
Copy 1
Copy 4
PERSONNELACTION
For useof this form, see AR600-8-6 and DAPAM600-8-21; the proponent agency is ODCSPER
DATAREQUIREDBY THEPRIVACY ACTOF1974
AUTHORITY:
PRINCIPALPURPOSE:
Title5, Section3012; Title 10, USC, E.O. 9397.
Usedby soldier inaccordancewith DAPAM600-8-21 when requesting apersonnel actiononhis/her ownbehalf
(Section III).
ROUTINEUSES:
Toinitiatetheprocessing of apersonnel actionbeing requestedby thesoldier.
DISCLOSURE:
Voluntary. Failureto providesocial security number may result in adelay or error in processingof therequest for
personnel action.
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
3. FROM (Include ZIP Code)
BATTALION ADDRESS
Headquarters
35th Sig Bde (Corps) (Airborne)
Fort Bragg, North Carolina 28310
COMPANY ADDRESS
SECTIONI - PERSONALIDENTIFICATION
4. NAME (Last, First, MI)
5. GRADEORRANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
SECTIONII - DUTY STATUS CHANGE (AR600-8-6)
7. Theabovesoldier's duty status is changed from
to
effective
hours,
SECTIONIII - REQUEST FORPERSONNELACTION
8. I request the followingaction: (Check as appropriate)
ServiceSchool (Enl only)
Special Forces Training/Assignment
IdentificationCard
ROTCor ReserveComponent Duty
On-the-JobTraining (Enl only)
Identification Tags
VolunteeringFor OverseaService
RetestinginArmy Personnel Tests
Separate Rations
Ranger Training
Reassignment MarriedArmy Couples
Leave- Excess/Advance/OutsideCONUS
Reassignment ExtremeFamily Problems
Reclassification
Change of Name/SSN/DOB
Officer CandidateSchool
Other (Specify)
Exchange Reassignment
(Enl only)
Airborne Training
Asgmt of Pers with Exceptional Family Members
9. SIGNATUREOFSOLDIER (When required)
10. DATE (YYYYMMDD)
SECTIONIV - REMARKS (Applies toSections II, III, and V) (Continue on separate sheet)
I request voluntary seoaration UP AR 635-200, paragraph 6-3b, for hardship. I am not under charges, in confinement, under
investigation, or pending consideration for separation per AR 635-40, Ar 604-10, Chapters 9, 11, 13, 14, or paragraph 5-8. I
request a separation date of ______________. I understand that if I have not completed my statutory servie obligation (10 USC
651), I may be transferred to the Individual Ready Reserve (IRR).
__
1.
2.
3.
4.
5.
6.
7.
Encls
Request for separation
Statement by / on behalf of dependant
Statement from __________
Statement from __________
Education Counseling
ERB & 2-1
ACAP Checklist
SECTIONV - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that therequest for personnel action (SectionIII) containedhereinHASBEEN VERIFIED
RECOMMENDAPPROVAL
12. COMMANDER/AUTHORIZEDREPRESENTATIVE
DA FORM 4187, JAN 2000
RECOMMENDDISAPPROVAL
13. SIGNATURE
PREVIOUS EDITIONS AREOBSOLETE
ISAPPROVED
ISDISAPPROVED
14. DATE (YYYYMMDD)
USAPA V1.00
39
APPENDIX K
Circletheappropriate copy designator
Copy 2
Copy 3
Copy 1
Copy 4
PERSONNELACTION
For useof this form, see AR600-8-6 and DAPAM600-8-21; the proponent agency is ODCSPER
DATAREQUIREDBY THEPRIVACY ACTOF1974
AUTHORITY:
PRINCIPALPURPOSE:
Title5, Section3012; Title 10, USC, E.O. 9397.
Usedby soldier inaccordancewith DAPAM600-8-21 when requesting apersonnel actiononhis/her ownbehalf
(Section III).
ROUTINEUSES:
Toinitiatetheprocessing of apersonnel actionbeing requestedby thesoldier.
DISCLOSURE:
Voluntary. Failureto providesocial security number may result in adelay or error in processingof therequest for
personnel action.
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
3. FROM (Include ZIP Code)
BATTALION ADDRESS
Headquarters
35th Sig Bde (Corps) (Airborne)
Fort Bragg, North Carolina 28310
COMPANY ADDRESS
SECTIONI - PERSONALIDENTIFICATION
4. NAME (Last, First, MI)
5. GRADEORRANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
SECTIONII - DUTY STATUS CHANGE (AR600-8-6)
7. Theabovesoldier's duty status is changed from
to
effective
hours,
SECTIONIII - REQUEST FORPERSONNELACTION
8. I request the followingaction: (Check as appropriate)
ServiceSchool (Enl only)
Special Forces Training/Assignment
IdentificationCard
ROTCor ReserveComponent Duty
On-the-JobTraining (Enl only)
Identification Tags
VolunteeringFor OverseaService
RetestinginArmy Personnel Tests
Separate Rations
Ranger Training
Reassignment MarriedArmy Couples
Leave- Excess/Advance/OutsideCONUS
Reassignment ExtremeFamily Problems
Reclassification
Change of Name/SSN/DOB
Officer CandidateSchool
Other (Specify)
Exchange Reassignment
(Enl only)
Airborne Training
Asgmt of Pers with Exceptional Family Members
9. SIGNATUREOFSOLDIER (When required)
10. DATE (YYYYMMDD)
SECTIONIV - REMARKS (Applies toSections II, III, and V) (Continue on separate sheet)
I request voluntary seoaration UP AR 635-200, paragraph 8, for pregnancy. I request a separation date of ______________.
However, I understand that the separation authority and my military physician will determine the separation date. I further
understand that the separation date must not be later than 30 days before expected date of delivery, or the latest date my military
physician will aluthorize me to travel, whichever is earlier. I understand that if I have not completed my statutory servie
obligation (10 USC 651), I may be transferred to the Individual Ready Reserve (IRR).
__
1.
2.
3.
4.
5.
6.
7.
Encls
Request for separation
Physical Exam
Pregnancy Counseling
Pregnancy Counseling Checklist
Education Counseling
ERB & 2-1
ACAP Checklist
SECTIONV - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that therequest for personnel action (SectionIII) containedhereinHASBEEN VERIFIED
RECOMMENDAPPROVAL
12. COMMANDER/AUTHORIZEDREPRESENTATIVE
DA FORM 4187, JAN 2000
RECOMMENDDISAPPROVAL
13. SIGNATURE
PREVIOUS EDITIONS AREOBSOLETE
ISAPPROVED
ISDISAPPROVED
14. DATE (YYYYMMDD)
USAPA V1.00
40
APPENDIX L
Circletheappropriate copy designator
Copy 2
Copy 3
Copy 1
Copy 4
PERSONNELACTION
For useof this form, see AR600-8-6 and DAPAM600-8-21; the proponent agency is ODCSPER
DATAREQUIREDBY THEPRIVACY ACTOF1974
AUTHORITY:
PRINCIPALPURPOSE:
Title5, Section3012; Title 10, USC, E.O. 9397.
Usedby soldier inaccordancewith DAPAM600-8-21 when requesting apersonnel actiononhis/her ownbehalf
(Section III).
ROUTINEUSES:
Toinitiatetheprocessing of apersonnel actionbeing requestedby thesoldier.
DISCLOSURE:
Voluntary. Failureto providesocial security number may result in adelay or error in processingof therequest for
personnel action.
1. THRU (Include ZIP Code)
2. TO (Include ZIP Code)
3. FROM (Include ZIP Code)
BATTALION ADDRESS
Headquarters
35th Sig Bde (Corps) (Airborne)
Fort Bragg, North Carolina 28310
COMPANY ADDRESS
SECTIONI - PERSONALIDENTIFICATION
4. NAME (Last, First, MI)
5. GRADEORRANK/PMOS/AOC
6. SOCIAL SECURITY NUMBER
SECTIONII - DUTY STATUS CHANGE (AR600-8-6)
7. Theabovesoldier's duty status is changed from
to
effective
hours,
SECTIONIII - REQUEST FORPERSONNELACTION
8. I request the followingaction: (Check as appropriate)
ServiceSchool (Enl only)
Special Forces Training/Assignment
IdentificationCard
ROTCor ReserveComponent Duty
On-the-JobTraining (Enl only)
Identification Tags
VolunteeringFor OverseaService
RetestinginArmy Personnel Tests
Separate Rations
Ranger Training
Reassignment MarriedArmy Couples
Leave- Excess/Advance/OutsideCONUS
Reassignment ExtremeFamily Problems
Reclassification
Change of Name/SSN/DOB
Officer CandidateSchool
Other (Specify)
Exchange Reassignment
(Enl only)
Airborne Training
Asgmt of Pers with Exceptional Family Members
9. SIGNATUREOFSOLDIER (When required)
Voluntary Separation
10. DATE (YYYYMMDD)
SECTIONIV - REMARKS (Applies toSections II, III, and V) (Continue on separate sheet)
I request voluntary seoaration UP AR 635-200, paragraph 16-5, because I signed a Declination of Continued Service Statement
(DCSS) on _______________. I request a separation date of ______________.
My BASD is _______________.
My ETS is _________________.
I understand that if I have not completed my statutory servie obligation (10 USC 651), I may be transferred to the Individual
Ready Reserve (IRR).
SECTIONV - CERTIFICATION/APPROVAL/DISAPPROVAL
11. I certify that the duty status change (Section II) or that therequest for personnel action (SectionIII) containedhereinHASBEEN VERIFIED
RECOMMENDAPPROVAL
12. COMMANDER/AUTHORIZEDREPRESENTATIVE
DA FORM 4187, JAN 2000
RECOMMENDDISAPPROVAL
13. SIGNATURE
PREVIOUS EDITIONS AREOBSOLETE
ISAPPROVED
ISDISAPPROVED
14. DATE (YYYYMMDD)
USAPA V1.00
41