APD LC v1.01
DA FORM 7666, SEP 2009
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
In accordance with this agreement the parties confirm the following stipulations of fact and terms of agreement:
a member of the United States Army, (hereinafter "the Soldier"), and
(hereinafter "the child"), date of birth
are the parents of
The parties agree that each has reviewed the attached Family Care Plan as set forth in Form DA 5305, which indicates that for the time period that the
The parties agree that each will cooperate with the execution of any additional documentation as may be necessary to facilitate the designation of
physical custody to the temporary guardian and effectuate this consent.
By the signatures below, each party indicates their consent to the arrangements outlined in the attached Family Care Plan and this agreement.
, born in
PARENTAL CONSENT
For use of this form, see AR 600-20; the proponent agency is DCS, G-1.
.
.
.
,
PRIVACY ACT STATEMENT
10 U.S.C. Section 3013, Secretary of the Army: Army Regulation 600-20, Army Command Policy.
To record the agreement of both parents with their child's custodial arrangement as documented in the Family
Care Plan.
None.
Mandatory; failure to maintain a Family Care Plan could subject you to separation, administrative action, or
disciplinary action under the UCMJ.
The child currently resides primarily with
As a function of performing military duties, the Soldier may have to perform temporary duty, be deployed, or otherwise not be available to care
for the minor child.
at
a.
The Soldier has been notified that he or she is to be temporarily deployed. The time period of deployment has been estimated to be
in length. As a matter of military necessity, the minor child will not be able to reside with, or exercise access to the
Soldier during this time.
(Initial appropriate paragraph)
b.
Soldier is absent,
is to serve as the minor child's temporary physical guardian.
The parties agree that during this period the minor child will reside at
STATE OF COUNTY OF
Acknowledged before me this
My commission expires:
day of .,
(NOTARY PUBLIC)
(NOTARY PUBLIC)
(SOLDIER'S SIGNATURE)
STATE OF COUNTY OF
Acknowledged before me this
My commission expires:
day of .,
(OTHER PARENT'S SIGNATURE)
