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PERSONNEL ACTION

For use of this form, see AR 600-8-6 and DA PAM 600-8-21; the proponent agency is ODCSPER.

 

DATA REQUIRED BY THE PRIVACY ACT OF 1974

 

AUTHORITY:

 

Title 5, Section 3012; Title 10, USC, E.O. 9397.

 

PRINCIPAL PURPOSE:

 

 

Used by soldier in accordance with DA PAM 600-8-21 when requesting a personnel action on his/her behalf (Section III).

 

ROUTINE USES:

 

To initiate the processing of a personnel action being requested by the soldier.

 

DISCLOSURE:

 

Voluntary.  Failure to provide social security number may result in a delay or error in processing of the request for personnel action.

 

 

1. THRU (Include ZIP Code)

 

Battalion Address

 

 

 

2. TO (Include ZIP Code)

 

Brigade Address

 

 

3. FROM (Include ZIP Code)

 

Company Address

 

SECTION I – PERSONAL IDENTIFICATION

4. NAME (Last, First, MI)

 

5. GRADE OR RANK/PMOS/AOC

 

 

6. SOCIAL SECURITY NUMBER

 

 

SECTION II – DUTY STATUS CHANGE (AR 600-8-6)

 

 

7.  The above soldier’s duty status has changed from

 

 

 

 

 

 

to

 

 

 

 

 

effective

 

 

hours,

 

 

19

 

 

 

 

 

 

 

 

SECTION III – REQUEST FOR PERSONNEL ACTION

8. I request the following action:

TYPE OF ACTION

PROCEDURE

TYPE OF ACTION

PROCEEDURE

 

Service School (Enl only)

 

 

Reassignment Married Army Couples

 

 

ROTC or Reserve Component Duty

 

 

Reclassification

 

 

Volunteering for Overseas Service

 

 

Officer Candidate School

 

 

Ranger Training

 

 

Asgmt of Pers with Exceptional Family Members

 

 

Reassignment Extreme Family Problems

 

 

Identification Card

 

 

Exchange Reassignment (Enl only)

 

 

Identification Tags

 

 

Airborne Training

 

 

Separate Rations

 

 

Special Forces Training/Assignment

 

 

Leave – Excess/Advance/Outside CONUS

 

 

On-the-Job Training (Enl only)

 

 

Change of Name/SSN/DOB

 

 

Retesting in Army Personnel Tests

 

X

Other (Specify) Request for Chapter 6 (Hardship)

 

 

9. SIGNATURE OF SOLDIER (When required)

 

10. DATE

 

SECTION IV – REMARKS (Applies to Sections II, III and V) (Continue on separate sheet)

 

I request voluntary separation UP AR 635-200, Paragraph 6-3b, for hardship.  I am not under charges, in confinement, under investigation, or pending consideration for separation per AR 635-40.  AR 604-10, or Chapters 9, 11, 13, 14, or paragraph 5-8.  I request a separation date of ______.  I understand that if I have not completed my statutory service obligation (10 USC 651), I may be transferred to the Individual Ready Reserve (IRR).

 

__ Encls

1.  Request for Separation                                  5.  ERB/2-1

2.  Stmt from __________                 

3.  Stmt from __________

4.  Stmt from __________

 

SECTION V – CERTIFICATION/APPROVAL/DISAPPROVAL

 

11.  I certify that the duty status change (Section II) or that the request for personnel action (Section III) contained herein –

 

 

p HAS BEEN VERIFIED

p  RECOMMEND APPROVAL

p  RECOMMEND DISAPPROVAL

 

 

p  IS APPROVED

 

p  IS DISAPPROVED

 

12. COMMANDER/AUTHORIZED REPRESENTATIVE

 

13. SIGNATURE

 

14. DATE

 

 

DA FORM  4187, OCT 93

DA FORM 4187, DEC 82 MAY BE USED

USAPPC V3.00                        COPY 1

 

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