Form Af Imt 357 – Fill Out and Use This PDF

FAMILY CARE CERTIFICATION

(PRIVACY ACT STATEMENT OF 1974 APPLIES - SEE BELOW)

AUTHORITY; 10 U.S.C. 8013 and E.O. 9397, Secretary of the Air Force: powers and duties; delegation by.

PRINCIPAL PURPOSE: To contact persons designated by the member as accepting family care responsibility, to verify their willingness to act for the member in this capacity, to advise the caregivers when they are expected to discharge these responsibilities and to insure member's compliance with the instruction.

ROUTINE USES: None.

DISCLOSURE IS VOLUNTARY; Use of the SSN is required to establish positive identification. Other information is required to ensure members have met their family care responsibilities.

Failure to provide the information may result in discharge from the Active Air Force, Air National Guard, or Air Force Reserve.

SECTION I. MEMBER'S CERTIFICATION

1.I have been counseled and fully understand Air Force policy on family care responsibilities pertaining to the performance of military duties. I have read and understand AFI 36-2908 and that I must arrange for family care so that I will remain worldwide available as defined in AFI 36-290, and I must report for duty as required without my family members. I affirm I have made and will maintain arrangements for the care of my family to permit me to be worldwide available during all the following circumstances: a. Duty Hours; b. Exercises; c. Unaccompanied Tours; d. Alerts; e. TDY; f. Extended Duty Hours; g. PCS or PCA, and h. Similar Military Obligations. I understand I am subject to deployment on short notice and I will not be guaranteed special privileges because I have family members. I understand if these arrangements for the care of my family fails, I must still report for duty.

2.I understand failure to make and maintain adequate family care arrangements may be grounds for disciplinary action and separation from the Air Force, Air National Guard and/or Air Force Reserve components. I understand I must verify or revise this plan at least yearly or on reassignment, reenlistment,

extension of enlistment, or if circumstances for family care change. I have made all necessary arrangements (legal, educational, monetary, religious, etc.) for a smooth, rapid turnover of family care responsibilities. I have arranged to complete travel that may be required to transfer my family members to the designated person. If my primary long term family caregiver is not in the local area, I understand I must arrange with a nonmilitary person in the local area to assume temporary custody of my family members until responsibility is transferred to my primary long term caregiver. I understand that while serving in an oversea area, I must arrange for escort and care of my family members if a Noncombatant Evacuation Operation (NEO) is implemented, I know I will be required to remain in place and perform my military duties.

3.All my family members are 19 or older and capable of self-care, (Initials) _____________.

4.I understand I may be subject to action under the Uniform Code of Military Justice (UCMJ) and/or appropriate Reserve component discharge authorities if this statement is not accurate.

A. DATE	TYPED OR PRINTED NAME, GRADE, AND SSN	SIGNATURE

(Complete Block B. only when a military couple with family members share a joint domicile and have the same family care plan.)

B. DATE	TYPED OR PRINTED NAME, GRADE, AND SSN	SIGNATURE

SECTION II. CAREGIVER CERTIFICATION (The following statements may be signed by as many as three different individuals or as few as one)

5.PRIMARY SHORT TERM CAREGIVER: I agree to accept responsibility for the family members of if he or she must

report for duty for extended work hours, recall or TDY for a duration of less than			days. I also certify that the financial and travel arrangements
made by the legal guardian are adequate for the care of their family members while in my custody. I					will			will not be authorized use of commissary
and BX facilities. I know of possible behavioral changes in the family members and the nearest assistance center.
TYPED OR PRINTED NAME	SIGNATURE									DATE

6. PRIMARY LONG TERM CAREGIVER: I agree to accept responsibility for the family members of if he or she is reassigned in an unaccompanied status or deployed TDY for a duration to exceed the responsibilities of the short term caregiver. I also certify the financial and

travel arrangements made by the legal guardian are adequate for the care of their family members while in my custody. I			will		will not be authorized
use of commissary and BX facilities. I know of possible behavioral changes in the family members and the nearest assistance center.
TYPED OR PRINTED NAME	SIGNATURE			DATE

7. ALTERNATE CAREGIVER: In the event the caregiver in item								(item 5 and/or 6) is unavailable, I agree to accept responsibility for the family
members of				I also certify that the financial and travel arrangements made by the guardian are adequate for the care of
their family members while in my custody. I			will			will not be authorized use of commissary and BX facilities. I know of possible behavioral changes
in the family members and the nearest assistance center.
TYPED OR PRINTED NAME							SIGNATURE		DATE

SECTION III. TEMPORARY CUSTODY DESIGNATION OF A DUAL MILITARY COUPLE OR SINGLE PARENT

8.TEMPORARY CUSTODY DESIGNEE: I agree in the event of their death or incapacity to assume temporary custody of their family members until a legal guardian is appointed by a court of competent jurisdiction.

TYPED OR PRINTED NAME	SIGNATURE	DATE

FAMILY CARE CERTIFICATION

(PRIVACY ACT STATEMENT OF 1974 APPLIES - SEE BELOW)

AUTHORITY; 10 U.S.C. 8013 and E.O. 9397, Secretary of the Air Force: powers and duties; delegation by.

PRINCIPAL PURPOSE: To contact persons designated by the member as accepting family care responsibility, to verify their willingness to act for the member in this capacity, to advise the caregivers when they are expected to discharge these responsibilities and to insure member's compliance with the instruction.

ROUTINE USES: None.

DISCLOSURE IS VOLUNTARY; Use of the SSN is required to establish positive identification. Other information is required to ensure members have met their family care responsibilities.

Failure to provide the information may result in discharge from the Active Air Force, Air National Guard, or Air Force Reserve.

SECTION I. MEMBER'S CERTIFICATION

1.I have been counseled and fully understand Air Force policy on family care responsibilities pertaining to the performance of military duties. I have read and understand AFI 36-2908 and that I must arrange for family care so that I will remain worldwide available as defined in AFI 36-290, and I must report for duty as required without my family members. I affirm I have made and will maintain arrangements for the care of my family to permit me to be worldwide available during all the following circumstances: a. Duty Hours; b. Exercises; c. Unaccompanied Tours; d. Alerts; e. TDY; f. Extended Duty Hours; g. PCS or PCA, and h. Similar Military Obligations. I understand I am subject to deployment on short notice and I will not be guaranteed special privileges because I have family members. I understand if these arrangements for the care of my family fails, I must still report for duty.

2.I understand failure to make and maintain adequate family care arrangements may be grounds for disciplinary action and separation from the Air Force, Air National Guard and/or Air Force Reserve components. I understand I must verify or revise this plan at least yearly or on reassignment, reenlistment,

extension of enlistment, or if circumstances for family care change. I have made all necessary arrangements (legal, educational, monetary, religious, etc.) for a smooth, rapid turnover of family care responsibilities. I have arranged to complete travel that may be required to transfer my family members to the designated person. If my primary long term family caregiver is not in the local area, I understand I must arrange with a nonmilitary person in the local area to assume temporary custody of my family members until responsibility is transferred to my primary long term caregiver. I understand that while serving in an oversea area, I must arrange for escort and care of my family members if a Noncombatant Evacuation Operation (NEO) is implemented, I know I will be required to remain in place and perform my military duties.

3.All my family members are 19 or older and capable of self-care, (Initials) _____________.

4.I understand I may be subject to action under the Uniform Code of Military Justice (UCMJ) and/or appropriate Reserve component discharge authorities if this statement is not accurate.

A. DATE	TYPED OR PRINTED NAME, GRADE, AND SSN	SIGNATURE

(Complete Block B. only when a military couple with family members share a joint domicile and have the same family care plan.)

B. DATE	TYPED OR PRINTED NAME, GRADE, AND SSN	SIGNATURE

SECTION II. CAREGIVER CERTIFICATION (The following statements may be signed by as many as three different individuals or as few as one)

5.PRIMARY SHORT TERM CAREGIVER: I agree to accept responsibility for the family members of if he or she must

report for duty for extended work hours, recall or TDY for a duration of less than			days. I also certify that the financial and travel arrangements
made by the legal guardian are adequate for the care of their family members while in my custody. I					will			will not be authorized use of commissary
and BX facilities. I know of possible behavioral changes in the family members and the nearest assistance center.
TYPED OR PRINTED NAME	SIGNATURE									DATE

6. PRIMARY LONG TERM CAREGIVER: I agree to accept responsibility for the family members of if he or she is reassigned in an unaccompanied status or deployed TDY for a duration to exceed the responsibilities of the short term caregiver. I also certify the financial and

travel arrangements made by the legal guardian are adequate for the care of their family members while in my custody. I			will		will not be authorized
use of commissary and BX facilities. I know of possible behavioral changes in the family members and the nearest assistance center.
TYPED OR PRINTED NAME	SIGNATURE			DATE

7. ALTERNATE CAREGIVER: In the event the caregiver in item								(item 5 and/or 6) is unavailable, I agree to accept responsibility for the family
members of				I also certify that the financial and travel arrangements made by the guardian are adequate for the care of
their family members while in my custody. I			will			will not be authorized use of commissary and BX facilities. I know of possible behavioral changes
in the family members and the nearest assistance center.
TYPED OR PRINTED NAME							SIGNATURE		DATE

SECTION III. TEMPORARY CUSTODY DESIGNATION OF A DUAL MILITARY COUPLE OR SINGLE PARENT

8.TEMPORARY CUSTODY DESIGNEE: I agree in the event of their death or incapacity to assume temporary custody of their family members until a legal guardian is appointed by a court of competent jurisdiction.

TYPED OR PRINTED NAME	SIGNATURE	DATE