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).
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
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