DA Form 5841 at a glance
What it is: DA Form 5841, the Power of Attorney, 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.
Who signs: Sign on the GRANTOR'S SIGNATURE line in the presence of the Notary Public witnessing it at your request.
A filled-in DA Form 5841 example: a soldier appoints a guardian for two children
How to fill out DA Form 5841, box by box
That I, of the state of, a member of the United States Armed Forces
Fill in the blank after "That I," and the blank after "of the state of".
Fill in the blank after "a" and the blank after "member of the United States Armed Forces, currently residing in".
Do hereby appoint
Fill in the blank after "pursuant to Military Orders, do hereby appoint" and the blank after "presently residing at"; this is your "true and lawful attorney-in-fact".
Guardianship of my child (ren)
After "To assume and maintain guardianship of my child (ren)," fill in the child(ren).
Your attorney-in-fact is to do all acts necessary or desirable for maintaining health, education, and welfare; to maintain customary living standards, including, but not limited to, provision of living quarters, food, clothing, medical, surgical and dental care; and, specifically, to approve and authorize any and all medical treatment deemed necessary by a duly licensed physician.
Null and void on
Fill in the blank after "NULL and VOID on". This Power of Attorney shall become NULL and VOID then, unless revoked or terminated by you.
If on the specified expiration date, or during the sixty (60) day period preceding it, you 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 you have returned to United States military control following termination of such status, UNLESS OTHERWISE REVOKED OR TERMINATED BY YOU.
This Power of Attorney shall become effective when you sign and execute it.
Signing with the Notary Public
Sign on the GRANTOR'S SIGNATURE line in the presence of the Notary Public witnessing it at your request.
After "at my request this date" fill in the date, and after "State of" and "County of" fill in the State and the County.
Acknowledgment by the notary public
The notary public certifies to be a fully commissioned, qualified, and authorized notary public.
Fill in the blank after "appeared": 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.
Fill in the day after "IN WITNESS WHEREOF, I have hereunto set my hand and affix my seal this", the blank after "of", and the STATE OF and COUNTY OF.
Fill in the day after "Acknowledged before me this" and the blank after "day of"; sign at (NOTARY PUBLIC); and fill in the blank after "My commission expires:".
More rules for DA Form 5841
You authorize your attorney to indemnify and hold harmless any third party who accepts and acts under or in accordance with this Power of Attorney.
You intend for this to be a DURABLE Power of Attorney: it will continue to be effective if you become disabled, incapacitated, or incompetent.
You authorize your 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.
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 on the first page 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.
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.
Failure to maintain a Family Care Plan could subject you to separation, administrative action, or disciplinary action under the UCMJ.
Common questions about DA Form 5841
When is this form not the right one?
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. 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.
Sources
[1] DA Form 5841 (JUL 2020), Power of Attorney, U.S. Army (the Official source link on this page).
