The Soldier understands they have no later than 45 days from the date they generated an SRR to extend, reenlist, or execute this statement.
Reenlistment: the Soldier will be prohibited from reenlistment or extension of enlistment at a later date.
Promotion list: the Soldier will be removed from the promotion recommended list by HQDA under the provision of AR 600-8-19.
Re-entry at ETS: the Soldier 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.
Re-entry before ETS: the Soldier may be prohibited from applying for re-entry into the Active Army for at least 2 years if voluntarily separated before current ETS.
Separation pay: the Soldier is not eligible for separation pay.
| Question | Answer |
|---|---|
| Form Name | DA Form 4991 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 39 |
| Avg. time to fill out | 7 min |
| Edition | APR 2023 |
| Proponent agency | DCS, G-1 (AR 601-280) |
| Who signs | The Soldier, the commander or first sergeant and the career counselor |
| Other names | DA Form 4991, DA 4991, DA4991, DA Form 4991-R, Form 4991, Declination of Continued Service Statement |
| Official source | DA Form 4991 (Rev APR 2023), DCS, G-1 |