Da Form 5841 R – Fill Out and Use This PDF

SPECIAL INSTRUCTIONS RELATED TO EXECUTION OF POWERS OF ATTORNEY

The DA Form 5841 is a special power of attorney (POA) that may be used to authorize a person to take care

of your child(ren) in your absence. It is important that you understand that you are not required to use this POA for your 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) will be living, a POA may not always be effective for your designated guardian to care for your child (ren) under any or all

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.

It is very important that the following persons be shown the POA or other appropriate documentation for the purpose of determining whether they will honor it:

Doctors, dentists, and hospital officials or other health care providers who may be called upon to treat your child (ren).

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.

If the persons identified above will not honor the POA, you must ask to be provided powers of attorney or other 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.

You must understand that a POA will not prevent another person, such as a non-custodial parent or relative of your child (ren), from petitioning a court of competent jurisdiction to obtain temporary or permanent custody of your children

POWER OF ATTORNEY

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

PRIVACY ACT STATEMENT

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

PRINCIPAL PURPOSE: To designate a guardian to care for your child (ren) in your absence.

DISCLOSURE:Mandatory; failure to maintain a Family Care Plan could subject you to separation, administrative action, or. disciplinary action under the UCMJ.

KNOW ALL PERSONS BY THESE PRESENTS:

member of the United States Armed Forces, currently residing in

, pursuant to Military Orders, do hereby appoint , presently residing at

, my true and lawful attorney-in-fact to do the

following acts or things in my name and in my behalf: To assume and maintain guardianship of my child (ren),

;

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.

I hereby give and grant individually unto my said attorney full power and authority to do and perform all and 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.

I intend for this to be a DURABLE Power of Attorney. This Power of Attorney will continue to be effective if I become disabled, incapacitated, or incompetent.

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.

I HEREBY RATIFY ALL THAT MY ATTORNEY SHALL LAWFULLY DO OR CAUSE TO BE DONE BY THIS DOCUMENT.

This Power of Attorney shall become effective when I sign and execute it below. Further, unless sooner revoked or terminated by me, this Power of Attorney shall become NULL and VOID on

.

Notwithstanding my inclusion of a specific expiration date herein, if on the above-specified expiration date,

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.

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

, who is known by me to be the person who is

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.

GRANTOR'S SIGNATURE

(Notary Public)

My commission expires: