DA Form 5840 PDF Details

For use of this form, see AR 600-20; the proponent agency is DCS, G-1.

Authority: 10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy.

Responsibility: I agree to accept responsibility for these family members.

Disclosure: Voluntary; However, failure to provide all the requested information could lead to rejection of a soldier's Family Care Plan.

Question	Answer
Form Name	DA Form 5840
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Edition	JUN 2010
Other names	DA Form 5840, DA 5840, DA5840, Certificate of Acceptance as Guardian or Escort
Official source	DA Form 5840 (JUN 2010), Certificate of Acceptance as Guardian or Escort, U.S. Army

How to Fill Out DA Form 5840

DA Form 5840 at a glance

What it is: DA Form 5840 is the Certificate of Acceptance as Guardian or Escort.

Who signs: The GUARDIAN signs in the SIGNATURE box and enters the DATE (YYYY/MM/DD), and the Notary Public signs at SIGN (Notary Public).

The principal purpose of the form is the guardian's agreement to care for a soldier's child(ren) in his or her absence.

A filled-in DA Form 5840 example: a grandmother accepts two children

DA Form 5840 example filled out, example: a grandmother accepts two children — Dana Sample signs DA Form 5840 as guardian of her son's children. Her son, a soldier, leaves Mia, age 7, and Noah, age 4, in her care. The picture shows the filled form, and its names and figures are sample values. Dana was given an original DA Form 5841, so the form names her as guardian. Two children fill two of the six boxes under Names and ages of family members, so the other four stay empty. One soldier is named, so the two extra lines under Family members of stay empty. Dana signs on March 14, 2026 before a notary public, who completes the notary lines.

How to fill out DA Form 5840, box by box

Guardian and authority

After I, enter your name. You were provided an original DA Form 5841 (Power of Attorney) or other legally sufficient authority naming you as guardian/escort.

Names and ages of family members

Under NAME (s) / AGE (s) OF FAMILY MEMBERS, enter the names and ages of the family members.

Family members of

After family members of:, enter the NAME (s).

Guardian's name and address

You agree to accept responsibility for these family members. You have received all necessary documents required to provide financial, medical, educational, quarters, and subsistence support for these family members. You have been briefed on procedures for accessing military/civilian facilities, services, benefits, and entitlements on behalf of these family members.

Enter the TYPED OR PRINTED NAME OF GUARDIAN and the ADDRESS (Include ZIP Code).

Enter the TELEPHONE NUMBER (Include Area Code) and the E-MAIL ADDRESS.

Notary public

Under NOTARY, the notary public enters the STATE OF, the COUNTY OF, the day of in Acknowledged before me this, and when My commission expires, and signs at (Notary Public).

More rules for DA Form 5840

Disclosure is voluntary; however, failure to provide all the requested information could lead to rejection of a soldier's Family Care Plan.

DA FORM 5840, JUN 2010: previous editions are obsolete.

Common questions about DA Form 5840

What is a DA form 5840?

DA Form 5840 is the Certificate of Acceptance as Guardian or Escort. For use of this form, see AR 600-20; the proponent agency is DCS, G-1.

Sources

[1] DA Form 5840 (JUN 2010), Certificate of Acceptance as Guardian or Escort, U.S. Army (the Official source link on this page).

DA Form 5840: Certificate of Acceptance as Guardian or Escort