Indebtedness

2012-02-10T22:45:00.000-08:00

Developmental Counseling FORM For use this form, see FM 6-22; the proponent agency in TRADOC.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Authority: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN) PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates. ROUTINE USES: The DoD Blanket Routine Uses set forth at the beginning of the Army’s compilation of systems or records also apply to this system DISCLOSURE: Disclosure is voluntary.
Part I - Administrative Data
Name (Last, First, MI)		Rank/Grade	Date of Counseling
Organization	Name and Title of Counselor
PART II - Background Information
Purpose of Counseling: (Leader states the reason for the counseling, e.g., Performance/Professional or Event-Oriented counseling and includes the leader’s facts and observations prior to the counseling): To: • Determine reason for non-payment of debt • Enact measures to prevent future occurrences • Inform soldier of his responsibility to properly manage funds/financial affairs • Inform soldier of possible consequences for continued non-payment
Part III - Summary of Counseling Complete this section during or immediately subsequent to counseling.
Key Points of Discussion
• On DATE you were administered an APFT. You achieved the following scores: o Pushups (reps/score): _____ /_____ Sit-ups (reps/score): _____/_____ 2 Mile run (reps/score): _____/_____ It has been brought to my attention that you currently have a debt with: 1. Rent-a-Center in the amount of $532.00, dated: 25 December 2004 As a soldier you have an obligation to pay your debts in a timely manner. Failure to do so reflects negatively upon you, the Unit, and the United States Army. I am giving you until DAY/DATE to provide me with proof that you have paid this debt in full or bring me written confirmation that you have established a plan with the creditor to pay the debt. This is your 1st offense concerning financial debts. After considering all the facts concerning you financial situation I am recommending to the commander that the following actions be taken: ____ You be scheduled for a budgeting class ____ You be scheduled for a check writing class ____ Recommendation of bar to reenlistment ____ Recommendation of flag (stops all favorable actions e.g. NCOES, civilian schools, promotion, etc.) ____ Recommendation for punishment under the UCMJ ____ Other:
OTHER INSTRUCTIONS This form will be destroyed upon: reassignment (other than rehabilitative transfers), separation at ETS, or upon retirement. For separation requirements and notification of loss of benefits/consequences see local directives and AR 635-200.

DA FORM 4856, AUG 2010 PREVIOUSE EDITIONS ARE OBSOLETE

Plan of Action: (Outlines actions that the subordinate will do after the counseling session to reach the agreed upon goal(s). The actions must be specific enough to modify or maintain the subordinate’s behavior and include a specific time line for implementation and assessment (Part IV below):

If you are scheduled for a class or an appointment with a financial advisor you will ensure that you bring all bills, debts, current LES, and prepare a list of creditors (with addresses) in the event that a loan consolidation may be suggested by the financial counselor. The more information you provide the better an advisor can assist you. This is your chance to correct this situation. Failure to correct this situation could result in adverse action (flags, bars, UCMJ) and/or chapter from the military.

Soldier provided the following reasons for the failure to pay debt:

Session Closing: (The leader summarizes the key points of the session and checks if the subordinate understands the plan of action. The subordinate agrees/disagrees and provides remarks if appropriate):

Individual counseled: I agree disagree with the information above.

Individual counseled remarks:

Signature of Individual Counseled: _________________________________ Date: ______________________

Leader Responsibilities: (Leader’s responsibilities in implementing the plan of action):

• Check receipt of payments/agreement of payment

• Conduct follow up counseling

• Ensure Soldier attends scheduled classes

Signature of Counselor: _________________________________________ Date: _____________________

Part IV - ASSESSMENT OF THE PLAN OF ACTION

Assessment: (Did the plan of action achieve the desired results? This section is completed by both the leader and the individual counseled and provides useful information for follow-up counseling):

Counselor: ___________________ Individual Counseled: __________________ Date of Assessment: _____

Note: Both the counselor and the individual counseled should retain a record of the counseling.

DA FORM 4856, AUG 2010

Indebtedness

Indebtedness

Developmental Counseling FORM