Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current...
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Transcript of Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current...
![Page 1: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/1.jpg)
Family Care PlanFamily Care PlanRank/Name: SFC Gamio, NelsonUnit/Section: Ops Co, DHHB/PMO (AT)Current Status______________________
![Page 2: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/2.jpg)
Family Care Plan ChecklistFamily Care Plan Checklist
1.Letter of Instruction Yes___ No___ Date________
2.DA Form 5304 - Family Care Plan Checklist Yes___ No___ Date________
3.DA Form 5305 - Family Care Plan Yes___ No___ Date________
4.DA Form 5840 – Long Term Certificate of Acceptance Yes___ No___ Date________a. notarized Yes___ No___
5.DA Form 5841 – Long Term Power of Attorney Yes___ No___ Date________ a. notarized Yes___ No___
6. DA Form 5840 – Short Term Certificate of Acceptance Yes___ No___ Date________ a. notarized Yes___ No___
7. DA Form 5841 – Short Term Power of Attorney Yes___ No___ Date________ a. notarized Yes___ No___
8. DA Form 4856 – Counseling by Commander Yes___ No___ Date________
9. DD Form 1172 - DEERS Enrollment form Yes___ No___ Date________
10.DD Form 2558 - Allotment form Yes___ No___ Date________
Certified by________________________________________ Date______________Recertified by______________________________________ Date_______________Recertified by______________________________________ Date_______________
![Page 3: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/3.jpg)
Family Care PlanLetter of Instruction
![Page 4: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/4.jpg)
Family Care Plan Counseling Checklist(DA Form 5304, Jun 2010)
(3 pages)
EXAM
PLE
![Page 5: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/5.jpg)
Family Care Plan(DA Form 5305, Jun 2010)
(2 pages)
EXAM
PLE
![Page 6: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/6.jpg)
Long Term Provider Certificate of Acceptance(DA Form 5840, Jun 2010)
(MUST BE NOTARIZED)
EXAM
PLE
![Page 7: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/7.jpg)
Long Term Provider Power of Attorney(DA Form 5841, Jun 2010)
(2 pages)(MUST BE NOTARIZED)
EXAM
PLE
![Page 8: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/8.jpg)
Short Term Provider Certificate of Acceptance(DA Form 5840, Jun 2010)
(MUST BE NOTARIZED)
EXAM
PLE
![Page 9: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/9.jpg)
Short Term Provider Power of Attorney(DA Form 5841, Jun 2010)
(2 pages)(MUST BE NOTARIZED)
EXAM
PLE
![Page 10: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/10.jpg)
Developmental Counseling Form(DA Form 4856, Aug 2010)
EXAM
PLE
![Page 11: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/11.jpg)
Application for Uniformed Services Identification CardDEERS Enrollment
(DD Form 1172, Aug 2002)(Must have the form signed from DEERS, not a copy of the dependant’s ID Card)
EXAM
PLE
![Page 12: Family Care Plan Rank/Name: SFC Gamio, Nelson Unit/Section: Ops Co, DHHB/PMO (AT) Current Status______________________.](https://reader030.fdocuments.us/reader030/viewer/2022032705/56649db35503460f94aa3777/html5/thumbnails/12.jpg)
Authorization to Start, Stop or Change an Allotment(DD Form 2558, Aug 2002)
EXAM
PLE
NO DATE
NO DATE