Transcription of PRIVACY ACT STATEMENT - ArmyWriter.com
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PRIVACY ACT STATEMENT - ArmyWriter.com
TELEPHONE NUMBER(Include Area Code)TYPED OR PRINTED NAME OF GUARDIANSIGNATUREDATE(YYYY/MM/DD)ADDRESS (Include ZIP Code)E-MAIL ADDRESSNOTARY:STATE OFCOUNTY OFAcknowledged before me thisMy commission expires:NAME(s) / AGE(s) OF FAMILY MEMBERSCERTIFICATE OF ACCEPTANCE AS GUARDIAN OR ESCORTFor use of this form, see AR 600-20; the proponent agency is DCS, (Power of Attorney) or other legally sufficient authority naming me as guardian/escort for:was provided an original DA Form 5841 NAME(s)day offamily members of:(Notary Public),.DA FORM 5840, JUN 2010 PREVIOUS EDITIONS ARE PE agree to accept responsibility for these family members. I have received all necessary documentsrequired to provide financial, medical, educational, quarters, and subsistence support for these familymembers.
TELEPHONE NUMBER (Include Area Code) TYPED OR PRINTED NAME OF GUARDIAN SIGNATURE DATE (YYYY/MM/DD) ADDRESS (Include ZIP Code) E-MAIL ADDRESS NOTARY: STATE OF COUNTY OF Acknowledged before me this My commission expires:
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