DA Form 5841 at a glance
What it is: 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.
A filled-in DA Form 5841 example: a Soldier appoints an attorney-in-fact for her children
How to fill out DA Form 5841, box by box
Tap a group of boxes to open it, and a picture to see it full size.
That I
Fill in after "That I,", after "of the state of", after "a member of the United States Armed Forces, currently residing in", and after ", pursuant to Military Orders, do hereby appoint".
After "do hereby appoint" write the attorney-in-fact, and after "presently residing at" write; the form prints ", 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 assume and maintain guardianship of my child (ren), write the child(ren).
The attorney-in-fact is 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.
The attorney-in-fact is to, specifically, 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.
However, failure to maintain a Family Care Plan could subject you to separation, administrative action, or disciplinary action under the UCMJ.
NULL and VOID on
This Power of Attorney shall become effective when I sign and execute it below.
Further, unless sooner revoked or terminated by me, write the expiration date after "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.
In the presence of the Notary Public
IN WITNESS WHEREOF, I sign, seal, declare, publish, make and constitute this as and for my Power of Attorney in the presence of the Notary Public witnessing it at my request this date: Sign on the GRANTOR'S SIGNATURE line and write the date.
Write the state after "State of" and write the county after ", County of".
ACKNOWLEDGMENT
The notary public certifies "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, the notary writes the name of the person who 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.
IN WITNESS WHEREOF, I have hereunto set my hand and affix my seal this: fill in the day line and the "of . ," line.
Fill in the "STATE OF" line and the "COUNTY OF" line, and fill in the "Acknowledged before me this day of . ," line.
Sign on the (NOTARY PUBLIC) line, and write the line "My commission expires:".
More rules for DA Form 5841
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.
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, and 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.
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, as I might and could do in my own person if personally present.
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.
Sources
[1] DA Form 5841 (JUL 2020), Power of Attorney (the Official source link on this page).
