DA Form 4991 at a glance
What it is: DA Form 4991 is the DECLINATION OF CONTINUED SERVICE STATEMENT.
Who signs: The Soldier signs under a. Soldier's Signature, the Commander/First Sergeant under b. Signature and the career counselor under 13b. Signature. If Soldier refuses to sign acknowledgment of counseling received, 11b. Signature is signed by the Witness.
A filled-in DA Form 4991 example: a Sergeant signs the statement
How to fill out DA Form 4991, box by box
Boxes 1 to 8, the Soldier's information
Enter 1. Name (Last, First, Middle), 2. Rank, 3. ETS and 4. DoDID under SOLDIER'S INFORMATION.
Enter 5. Unit/Organization, 6. SRR End Date and 7. Date SRR Generated.
Box 8: You have incurred a service remaining requirement under the provisions of Chapter 4, AR 601-280 as a result of: enter in Box 8 after it.
Section A, Box 9, the Soldier's initials
9. Soldier understands their ETS must be equal to, or later than, the date noted in block 6 to comply with their incurred SRR.
The Soldier will signify understanding of all career effects by placing initials in the spaces provided.
a. I understand I have no later than 45 days from the date I generated an SRR to extend, reenlist, or execute this statement.
b. I understand I will be prohibited from reenlistment or extension of enlistment at a later date.
c. I understand I will be removed from the promotion recommended list by HQDA under the provision of AR 600-8-19.
d. I understand I may be prohibited from applying for re-entry into the Active Army for a period of at least 93 days if separated at current ETS, and at least 2 years if voluntarily separated before current ETS.
e. I understand I am prohibited from application, election, or attendance for commissioning or warrant officer programs while on the current period of active duty.
f. I understand I may be eligible to request voluntary separation under the provisions of AR 635-200.
g. I understand I may be eligible to join the Reserve Component.
h. I understand I may be considered eligible for other assignments (CONUS and OCONUS) provided I have sufficient service remaining to meet the requirements of the new assignment.
i. I understand I am not eligible for separation pay.
Section B, Box 10, the Soldier's acknowledgement of counseling
10. I hereby acknowledge I have been counseled concerning action required by me to satisfy a length-of-service requirement incident to a service obligation, and regarding my declination to extend my enlistment or reenlist to comply with the commitment. I understand the effects my declination will have on my Army career and on any future decision I might make concerning reenlistment or enlistment after separation.
Enter a. Soldier's Signature and b. Date (YYYYMMDD).
Box 11, if the Soldier refuses to sign
If Soldier refuses to sign acknowledgment of counseling received, complete 11a, 11b and 11c.
Enter a. Name, Rank of Witness, b. Signature and c. Date (YYYYMMDD).
Section C, Box 12, the commander's or first sergeant's review
I have reviewed and discussed the statement with the Soldier and have determined that the Soldier has been properly counseled. The Soldier refused to take action to acquire sufficient service to comply with the operational commitment.
Enter a. Name, Rank, and Branch of Commander/First Sergeant, b. Signature and c. Date (YYYYMMDD).
Section D, Box 13, the career counselor
Enter 13a. Name, Rank, and Title, 13b. Signature and 13c. Date (YYYYMMDD).
More rules for DA Form 4991
PRINCIPAL PURPOSE: To explain the conditions under which continued entitlement of the incentive may be terminated and earned portion of advanced incentive payments recouped. For additional information see the System of Records Notice A0600-8-104 AHRC APS https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/Army/A006-8-104-AHRC.pdf. A0601-280b AHRC SRB https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570079/0601-280b-ahrc.
DISCLOSURE: Voluntary. However, failure to furnish information requested may result in denial of retention incentive in the Army.
Sources
[1] DA Form 4991 (APR 2023), Declination of Continued Service Statement, U.S. Army (the Official source link on this page).