U.S. DOD Form dod-ngb-4991-r
DECLINATION OF CONTINUED SERVICE STATEMENT
For use of this form, see NGR 600-200. The proponent agency is NGB-ARH-E
So ldier's na me
S SN
G rade of Ran k
Uni t of assignment
1: having incurred a service-remaining requirement per NGR 600-200, chapter 7, as a result of
and whose ETS date is
with this commitment, must have a minimum of
in order to comply
months remaining to ETS as of
2: or, is eligible and available for an assignment per NGR 600-200, chapter 5, 9 or 11.
SECTION A - COUNSELING BY DESIGNATED OFFICIAL
1. The soldier has been advised as to -- a: the options available to acquire sufficient remaining service to satisfy the commitment, but has refused to
extend or immediately reenlist to meet the length-of-service requirement; or -- b: the requirement to accept an assignment for which eligible and
available. The soldier will initial in the space provided next to all career effects showing understanding of each statement. Each entry is affirmation
that the soldier understands and is stating that: "I understand that I will --"
Have 30 days after the date of notification to extend or reenlist (or accept an assignment) or execute this statement.
Be placed in a nonpromotable status per NGR 600-200, chapter 11.
Be prohibited from extension and immediate reenlistment and that it is a HODA (NGB) bar per NGR 600-200, chapter 7.
Be prohibited from reentry into the Army National Guard for at least two years and one day per NGR 600-200, chapter 8.
If eligible for retired pay at age 60, be prohibited from reentry into the Army National Guard per NGR 600-200, chapter 8.
Be prohibited from application, election, or attendance for commissioning or warrant officer appointment programs.
Be precluded from consideration for promotion and training per NGR 600-200, chapter 11.
Be allowed to request voluntary separation per NGR 600-200, chapter 8.
Be precluded from attendance at any schooling at Army expense, whether functional or leadership.
Not be eligible for separation pay if I am on active duty or full-time National Guard duty.
1a. NAME, GRADE AND BRANCH OF OFFICIA L
1b. ADVISO R'S SIGNATURE
1c. P LACE WHERE SOLDIER WA S A DV IS ED
1d. DATE (YYY YMMDD)
1e. TIME
SECTION B - COUNSELING BY RECRUITING AND RETENTION NCO
2. The undersigned Recruiting and Retention NCO also counseled the above named soldier concerning the various option available to satisfy the
service-remaining requirement, and the effects of referral to take action to meet the length-of-service requirement, or to accept an assignment. The
soldier again refused to comply.
2a. NAME, GRADE AND O RG ANIZATIO N OF R& R NCO
2b. RECRUITING AND RETENTIO N NCO 's SIGNATURE
2c. P LACE WHERE SOLDIER WA S A DV IS ED
2d. DATE (YYY YMMDD)
2e. TIME
SECTION C - SOLDIER'S ACKNOWLEDGEMENT OF COUNSELING
3. I acknowledge that I have been counseled by the above officials concerning action required by me to satisfy a length-of- service requirement
incident to a military commitment, and regarding my refusal to extend my enlistment or reenlist to comply with the commitment, or to accept an
assignment for which I am eligible and available. I understand the effects mt refusal will have on my military career and on ant future decision I might
make concerning reenlistment or extension after separation.
3a. NAME, GRADE AND O RG ANIZATIO N OF R& R NCO
3b. RECRUITING AND RETENTIO N NCO 's SIGNATURE
3c. P LACE WHERE SOLDIER WA S A DV IS ED
3d. DATE (YYY YMMDD)
2e. TIME
SECTION D - COMMANDER'S REVIEW
4. I have reviewed and discussed the above statement with the soldier and have determined that the soldier has been properly counseled. The
soldier refused to take action to acquire sufficient service to comply with the military commitment, or accept the assignment.
4a. NAME, GRADE AND BRANCH OF COMMANDER
NGB FORM 4991-R, APRIL 2001 (Adobe v 4.0)
4b. COMMANDE R'S SIGNATURE
PREVIOUS EDITIONS A RE O BSOL ETE