DEPARTMENT OF THE NAVY FAMILY CARE CERTIFICATE

REQUIRING DIRECTIVE OPNAVINST 1740.4

PRIVACY ACT 

AUTHORITY: 10 U.S.C. Section 5013, Secretary of the Navy and OPNAVINST 1740.4D 

PRINCIPAL PURPOSE: To identify and ensure that single military members and military couples with dependents have made adequate dependent 

care arrangements. To ensure the member is world-wide assignable. To ensure combat readiness and document a plan for the care of family 

members in the event of a medium or long term absence. To evaluate compliance with DOD and Navy programs requiring Family Care Plans. To 

ensure family members are cared for during deployments, reserve mobilizations, temporary duty, etc. and that arrangements are in place for the 

financial well being of family members covered by the Family Care Plan during separations. 

ROUTINE USES: Used by the Commanding Officer or his/her representative to ensure Family Dependent Care Program is in place. 

DISCLOSURE: Individuals who fail to maintain a current Family Care Plan may be subject to separation from the Navy (OPNAVINST 1740.4D 

paragraph 7.d.(6)). 

 PART I. SERVICEMEMBERS ACKNOWLEDGEMENT

 1. I have been counseled and fully understand Navy policy on dependent care responsibilities. I have read and understand the Navy's 

policy that I must arrange for dependent care so that I will remain worldwide available as defined, and that I must report for duty without 

dependents, as required.

INITIALS

 2. I understand that failure to make and maintain an adequate Family Care Plan in accordance with the Navy's policy may be grounds 

for disciplinary action or separation from the Navy, or both.

 3. I understand that I may be subject to action under the Uniform Code of Military Justice if this statement is not accurate.

 4. I understand that I am subject to deployments on short notice and that I will not be given special privileges because I have 

dependents.

 5. My normal working hours are from to . I have made arrangements for the care of my family members 

during these hours as well as absences due to extended working hours and the execution of my military duties. I understand that if 

these arrangements for the care of my dependents fail, my absence from assigned duty is without authority unless I have been excused 

by my commanding officer.

 6. I affirm that I have made and will maintain arrangements for the care of my dependents to permit me to be worldwide available 

during Duty Hours, Extended Duty Hours, Exercises, Unaccompanied Tours, Temporary Additional Duty, Permanent Change of Station, 

and other similar military obligations. 

 7. I understand that I must revise or verify this plan at least yearly or on reassignment, reenlistment, extension of enlistment, or within 

60 days (90 days for Ready Reserve) of any change in my family or caregiver status.

 8. I understand that while serving in an overseas area, I must arrange for the escort and care of my dependents by the designated 

person. If my principal caregiver is not in the local area, I understand that I must arrange with a nonmilitary person in the local area to 

assume temporary responsibility for my dependents until that responsibility is transferred to my principal caregiver.

 9. In the event of my death or incapacity, (name, address, telephone number) 

 

 

has agreed to assume temporary responsibility for my minor children until the guardian named in my will assumes responsibility, or until 

a legal guardian or other custodian is appointed by a court of competent jurisdiction, or until my child(ren)'s non-custodial natural parent 

assumes custody, whichever occurs first. 

 

 10. The attached form (NAVPERS 1740/7) explains what financial arrangements have been made to provide support for my family 

member(s) while they are under someone else's care, what logistical arrangements have been made to get my family members to the 

designated caregiver; where to go for routine and emergency medical treatment for my family member(s), and what the caregiver 

should do in the event they are no longer able to care for my family members.

11. TYPED OR PRINTED NAME OF MEMBER: 12. RANK/RATE:

15. MEMBER'S SIGNATURE:

NAVPERS 1740/6 (Rev. 02-2011) FOR OFFICIAL USE ONLY 

PRIVACY SENSITIVE

PAGE 1 OF 3

14. DATE (YYYYMMDD):

 13. BLOCK 

 

 (NOT USED)
DEPARTMENT OF THE NAVY FAMILY CARE CERTIFICATE (CONTINUED)

 PART II. CAREGIVER ACKNOWLEDGEMENT

16. Member's absence is for a duration of less than 30 days. 

16C. SIGNATURE OF CAREGIVER:

16A. TYPED OR PRINTED NAME OF CAREGIVER:

16D. TELEPHONE NUMBER OF CAREGIVER (INCLUDE AREA CODE):

16B. ADDRESS OF CAREGIVER:

16E. TYPED OR PRINTED NAME OF WITNESS: 16F. WITNESS' SIGNATURE:

17. Member's absence is for a duration of greater than 30 days. 

17E. TYPED OR PRINTED NAME OF WITNESS: 17F. WITNESS' SIGNATURE:

17D. TELEPHONE NUMBER OF CAREGIVER (INCLUDE AREA CODE):

17C. SIGNATURE OF CAREGIVER:

17A. TYPED OR PRINTED NAME OF CAREGIVER: 17B. ADDRESS OF CAREGIVER:

19. Statement of Military Spouse: I have read my spouse's plan and concur.

18. Applies to single servicemember sponsors & dual military couples with dependents serving overseas and accompanied by 

dependents.

18A. I agree to be responsible for accompanying and caring for the family members of 

 as an escort if evacuation from an overseas area becomes necessary.

18B. TYPED OR PRINTED NAME OF ESCORT: 18C. SIGNATURE OF ESCORT:

18D. TYPED OR PRINTED NAME OF WITNESS: 18E. WITNESS' SIGNATURE:

PART III. FOR DUAL MILITARY COUPLES ONLY

19A. SPOUSE'S COMMAND: 19B. COMMAND'S FAMILY CARE PLAN COORDINATOR AND 

TELEPHONE NUMBER:

19C. TYPED OR PRINTED NAME OF SPOUSE: 19D. SPOUSE'S SIGNATURE:

PAGE 2 OF 3 FOR OFFICIAL USE ONLY 

PRIVACY SENSITIVE

NAVPERS 1740/6 (Rev. 02-2011)

REQUIRING DIRECTIVE OPNAVINST 1740.4
DEPARTMENT OF THE NAVY FAMILY CARE CERTIFICATE (CONTINUED)

REQUIRING DIRECTIVE OPNAVINST 1740.4

20. ADDITIONAL COMMENTS:

22A. TYPED OR PRINTED NAME OF COMMANDING OFFICER: 22B. SIGNATURE OF COMMANDING OFFICER: 22C. DATE (YYYYMMDD):

22. I have reviewed this Family Care Plan and (I am/I am not) satisfied that the member has made adequate family care arrangements 

that will allow for a full range of military duties and for worldwide availability as defined here.

PART V. COMMAND CERTIFICATION

PART IV. CONSENTING NATURAL OR ADOPTIVE PARENT

21. I have reviewed this Family Care Plan and concur.

21A. TYPED OR PRINTED NAME: 21B. SIGNATURE: 21C. DATE (YYYYMMDD):

FOR OFFICIAL USE ONLY 

PRIVACY SENSITIVE

NAVPERS 1740/6 (Rev. 02-2011) PAGE 3 OF 3