Fillable Printable Family Care Plan
Fillable Printable Family Care Plan
Family Care Plan
TYPED OR PRINTED NAME
TELEPHONE NUMBER (Include Area Code)
2b. E- MAIL ADDRESS
FAMILY CARE PLAN
For use of this form, see AR 600-20; the proponent agency is DCS, G-1.
COMPLETE ADDRESS (Including Street, Apartment Number,
P.O. Box Number, Rural Route Number, City, State, and ZIP + 4
where applicable)
2a.
PART II - DESIGNATION OF GUARDIANS/ESCORTS
E.
C.
B. I have made and will maintain arrangements for the care of my family members during all the following:
1.
2.
3.
4.
5.
INITIALS
3.
1.
A .
A.
I.
I am confident that my Family Care Plan is workable, and to the best of my knowledge, the guardian (s) and escort (s) I have
designated will be both willing and able to carry out the responsibilities of caring for my family members.
H.
G.
F.
A copy of DA Form 5841 (Power of Attorney) or equivalent documents and a copy of DA Form 5840 (Certificate of Acceptance
as Guardian or Escort) for each escort or guardian whether temporary or long-term is attached to this plan.
2.
1.
D.
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 accordance with AR 600-75.
5.
4.
3.
I was counseled on
PART I - SOLDIER'S FAMILY CARE
(date) , and fully understand the policy on family member
Duty
Exercises/field duty
Permanent Change of Station
Alerts
Annual Training
6.
7.
8.
9.
10.
Temporary Duty
Unit Training Assembly
Active Duty Training
Unaccompanied Tours
Mobilization
Nonavailability for worldwide assignment and/or unit deployment may lead to my separation from the Army.
I have made all necessary arrangements (legal, educational, financial, religious, special, etc.) to ensure a smooth, rapid turnover
of family member care responsibilities in case this plan is implemented.
1. DD Form 1172 (Application for Uniformed Services Identification Card - DEERS Enrollment) for each family member whether they
have a currently valid ID card or not.
2. DD Form 2558 (Authorization to Start, Stop or Change an Allotment) or other proof of financial support for expenses incurred
by guardian and family members.
3. Copies of Letters of Instruction (which have been forwarded to designated escorts or guardians along with powers of attorney and
other pertinent documents), outlining all special instructions concerning the care of my family members have also been included in
my Family Care Plan.
DA FORM 5305, JUN 2010
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00ES
11.
12.
13.
14.
Deployment
Other Military Duty
Emergencies
Leave/non-duty Time
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy and E.O. 9397.
None
PRIVACY ACT STATEMENT
I (We) have designated the following temporary guardian to care for my (our) family member (s) until responsibility is transferred to escort or
principal (long-term) guardian.
Mandatory; Failure to maintain a Family Care Plan could subject the soldier to separation, administrative action, or
disciplinary action under the UCMJ.
To emphasize to soldiers the significance of their responsibilities to the military service and their family members while
performing required military duties.
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.
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 nature of both these requirements:
Failure to make and maintain adequate family member care arrangements in accordance with the Army's policy is grounds for
disciplinary action or separation.
If arrangements for the care of my family members fail to work, I am not automatically excused from prescribed duties, unit
deployment, or reassignment.
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.
I must maintain an up-to-date Family Care Plan and revise my Plan when circumstances change. I understand that Family Care
Plans may be tested at the discretion of the commander.
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 have arranged with a nonmilitary person in the local area to assume temporary guardianship of my family
members until they are transferred to my principal care designee, or that designee arrives to assume responsibility for their care.
The following additional required documents are completed, included in this plan, and will be put into effect as part of my Family Care
Plan.
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 and benefits on behalf of my family members.
TYPED OR PRINTED NAME OF COMMANDER
2. UNIT ADDRESS
DATE (YYYY/MM/DD)
SIGNATURE OF COMMANDER
SIGNATURE OF SPOUSE
TYPED OR PRINTED NAME OF SPOUSE
TYPED OR PRINTED NAME
TELEPHONE NUMBER (Include Area Code)
TYPED OR PRINTED NAME
TELEPHONE NUMBER (Include Area Code)
DATE DATE DATE DATE DATE
DATE DATE DATE DATE DATE
SIGNATURE OF SOLDIER
DATE (YYYY/MM/DD)
TYPED OR PRINTED NAME OF SOLDIER
DATE DATE DATE DATE DATE
SIGNATURE OF COMMANDER 2. UNIT ADDRESS
TYPED OR PRINTED NAME OF COMMANDER
DATE DATE DATE DATE DATE
E-MAIL ADDRESS
COMPLETE ADDRESS (Including Street, Apartment Number,
P.O. Box Number, Rural Route Number, City, State, and ZIP + 4
where applicable)
2a.
COMPLETE ADDRESS (Including Street, Apartment Number,
P.O. Box Number, Rural Route Number, City, State, and ZIP + 4
where applicable)
2a.
2b.
B.
PART III - DUAL MILITARY COUPLES ONLY
MILITARY SPOUSE AND COMMANDER CERTIFICATION
5.
4.
5.
4.
DATE
4.
3.
2.1.
1.
B.
Recertification
3.
A .
Spouse: We have made arrangements and will maintain arrangements for the care of our family member(s) in all circumstances required by our
commitment to the military and our family.
C.
I (We) have designated the following individual(s) as escort for my(our) family member(s) if evacuation from OCONUS becomes necessary (applies
only to persons assigned OCONUS):
3.
1.
3.
1.
a. INIT. b. INIT. c. INIT. d. INIT. e. INIT.
Commander: I have counseled the military spouse assigned to my unit, reviewed the Family Care Plan, and I am satisfied that the members have
made adequate family care arrangements.
Recertification
a. INIT. b. INIT. c. INIT. d. INIT. e. INIT.
PART IV - SOLDIER AND COMMANDER CERTIFICATION
DATE
4.
3.
2.1.
1.
B.
Recertification
3.
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.
a. INIT. b. INIT. c. INIT. d. INIT. e. INIT.
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 worldwide availability as defined here.
Recertification
a. INIT. b. INIT. c. INIT. d. INIT. e. INIT.
REVERSE OF DA FORM 5305, JUN 2010
APD LC v1.00ES
I (We) have designated the following individual(s) as principal long-term guardian(s) for my(our) family member(s). The designated guardian(s)
reside in the continental United States or United States territories.
E-MAIL ADDRESS2b.
