Fill and Sign DA 7574 Forms

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What Is DA Form 7574 Series?

The DA Form 7574 Series is a set of three Department of the Army-released forms related to the proper documentation and determination of an injured or ill service member‘s eligibility to receive incapacitation payments.

  1. DA Form 7574, Incapacitation Pay Monthly Claim Form, is a form used to provide and document the data necessary to determine a service member's eligibility for incapacitation pay. In addition to the claimant information and signature, the document must also be filled in and signed by their employer, commander, and higher headquarters or approving authority. A separate copy of the form must be completed and submitted for each calendar month the soldier wants to receive payments for.
  2. DA Form 7574-1, Military Physician's Statement of Soldier's Incapacitation/Fitness for Duty, is a medical form used for verifying either the eligibility or the ineligibility of a soldier to perform their military duties and their civilian job. This document can be valid for three months only and may be renewed if necessary upon its termination. The soldier is not allowed to perform any military tasks until a U.S. government physician or military doctor determines them fit for duty.
  3. DA Form 7574-2, Soldier's Acknowledgement of Incapacitation Pay Counselling, is a form through which the soldier acknowledges having been counseled on their rights and responsibilities after sustaining a military-related injury or illness еhat prevents them from performing military duties. A commander or designated representative must counsel the soldier on the list of conditions under which they may become eligible for incapacitation pay. By signing the form, the service member acknowledges being aware of their duties, rights, and the penalties for providing incomplete or false information on the claim. The DA 7574-2 should be witnessed by the counseling commander.

A service member has the right to file an incapacitation pay claim if a disease, illness, or injury results in an inability to fulfill either military duties or civilian employment and causes a loss or decrease of non-military earnings. The injury or illness has to be incurred during either active or inactive duty.

To be determined as eligible for receiving incapacitation pay, the service member will need to complete the DA Form 7574, DA Form 7574-1, and DA Form 7574-2. The filed and signed claim is certified by physicians, commanders, and employers and is submitted through the chain of command for further review.

Documents

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DA Form 7574 "Incapacitation Pay Monthly Claim"

Rate (4.5 / 5) 86 votes
Size: 95 KB
3 pages

This form is for claiming incapacitation pay and providing the information necessary to determine the service member's eligibility to receive it.

DA Form 7574-1 "Military Physician's Statement of Soldier's Incapacitation/Fitness for Duty"

Rate (4.6 / 5) 62 votes
Size: 58 KB
2 pages

Fill out this form if you are a military physician in order to provide conclusions regarding either the ability or inability of a service member to perform their duties.

DA Form 7574-2 "Soldier's Acknowledgement of Incapacitation Pay Counseling"

Rate (4.7 / 5) 60 votes
Size: 40 KB
1 page

Fill out this form if you are a service member in order to testify that you received proper incapacitation pay counseling.