Fillable Printable Power Of Attorney
Fillable Printable Power Of Attorney
Power Of Attorney
The DA Form 5841 is a special power of attorney (POA) that may be used to authorize a person to take care
It is very important that the following persons be shown the POA or other appropriate documentation for the
If the persons identified above will not honor the POA, you must ask to be provided powers of attorney or other
You must understand that a POA will not prevent another person, such as a non-custodial parent or relative of
Any school officials or other officials who may need your permission to provide services for your child (ren)
or register your child(ren) in school.
SPECIAL INSTRUCTIONS RELATED TO EXECUTION OF POWERS OF ATTORNEY
of your child(ren) in your absence. It is important that you understand that you are not required to use this POA for your
will be living, a POA may not always be effective for your designated guardian to care for your child(ren) under any or all
purpose of determining whether they will honor it:
your child(ren), from petitioning a court of competent jurisdiction to obtain temporary or permanent custody of your children
Family Care Plan. You may seek legal assistance to have a different POA drafted that better provides for your family
members if you so desire. You must also understand that depending on the law or other requirements where your child(ren)
Doctors, dentists, and hospital officials or other health care providers who may be called upon to treat your
child(ren).
documents that will be honored. You should show this POA or other documentation to all facilities, institutions, and
individuals to ensure they will recognize it for the purposes you have intended.
circumstances. You may seek legal assistance to advise you about the effectiveness of DA Form 5841, other POAs or any
other matters in your Family Care Plan.
POWER OF ATTORNEY
For use of this form, see AR 600-20; the proponent agency is DCS, G-1.
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PREVIOUS EDITION IS OBSOLETE.
DA FORM 5841, SEP 2009
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
KNOW ALL PERSONS BY THESE PRESENTS:
member of the United States Armed Forces, currently residing in
following acts or things in my name and in my behalf:
To assume and maintain guardianship of my child (ren),
I become disabled, incapacitated, or incompetent.
That I,
I hereby give and grant individually unto my said attorney full power and authority to do and perform all and
I intend for this to be a DURABLE Power of Attorney. This Power of Attorney will continue to be effective if
of the state of
, pursuant to Military Orders, do hereby appoint
, presently residing at
, my true and lawful attorney-in-fact to do the
POWER OF ATTORNEY
For use of this form, see AR 600-20; the proponent agency is DCS, G-1.
, a
,
;
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DA FORM 5841, SEP 2009
PRIVACY ACT STATEMENT
10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy.
To designate a guardian to care for your child(ren) in your absence.
None.
I authorize by attorney-in-fact to hire legal counsel in order to carry out the provisions of this document or
determine the existence of legal requirements, such as required filing or placement of notices, which may affect the validity
of this document.
any act, deed, matter and thing whatsoever in and about any of the aforementioned specified particulars as fully and
effectually to all intents and purposes as I might and could do in my own person if personally present; and in addition
thereto. I do hereby ratify and confirm each of the acts of my aforesaid attorneys lawfully done pursuant to the authority
herein above conferred.
I HEREBY AUTHORIZED MY ATTORNEY TO INDEMNIFY AND HOLD HARMLESS ANY THIRD PARTY
WHO ACCEPTS AND ACTS UNDER OR IN ACCORDANCE WITH THIS POWER OF ATTORNEY.
to do all acts necessary or desirable for maintaining health, education, and welfare; and to maintain customary living
standards, including, but not limited to, provision of living quarters, food, clothing, medical, surgical and dental care,
entertainment and other customary matters; and, specifically, to approve and authorize any and all medical treatment
deemed necessary by a duly licensed physician and to execute any consent, release or waiver of liability required by
medical or dental authorities incident to the provision of medical, surgical or dental care to any of them by qualified medical
or dental personnel.
Mandatory; failure to maintain a Family Care Plan could subject you to separation, administrative action, or.
disciplinary action under the UCMJ.
STATE OF
COUNTY OF
Acknowledged before me this
My commission expires:
I HEREBY RATIFY ALL THAT MY ATTORNEY SHALL LAWFULLY DO OR CAUSE TO BE DONE BY THIS
DOCUMENT.
revoked or terminated by me, this Power of Attorney shall become NULL and VOID on
or during the sixty (60) day period preceding that specified expiration date, I should be or have been determined by the
United States Government to be in a military status of "missing," "missing in action," or "prisoner of war," then this Power of
Attorney shall remain valid and in full effect until sixty (60) days after I have returned to United States military control following
termination of such status UNLESS OTHERWISE REVOKED OR TERMINATED BY ME.
, who is known by me to be the person who is
IN WITNESS WHEREOF, I sign, seal, declare, publish, make and constitute this as and for my Power of
Attorney in the presence of the Notary Public witnessing it at my request this date
State of
I, the undersigned, certify that I am a fully commissioned, qualified, and authorized notary public. Before
me personally, within the territorial limits of my warrant of authority, appeared
, County of
,
.
This Power of Attorney shall become effective when I sign and execute it below. Further, unless sooner
Notwithstanding my inclusion of a specific expiration date herein, if on the above-specified expiration date,
IN WITNESS WHEREOF, I have hereunto set my hand and affix my seal this
of ,
day
ACKNOWLEDGMENT
day of .,
GRANTOR'S SIGNATURE
(NOTARY PUBLIC)
.
described herein, whose name is subscribed to, and who signed the Power of Attorney as grantor, and who, having been duly
sworn, acknowledged that this instrument was executed after its contents were read and duly explained, and that such
execution was a free and voluntary act and deed for the uses and purposes herein set forth.
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DA FORM 5841, SEP 2009
POWER OF ATTORNEY
For use of this form, see AR 600-20; the proponent agency is DCS, G-1.
