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

What Is DA Form 7574-2?

DA Form 7574-2, Soldier's Acknowledgement of Incapacitation Pay Counselling is a form that testifies to the fact proper incapacitation pay counseling had been received by a service member that sustained an injury, illness, or disease while performing their military duties.

An up-to-date of the form – sometimes incorrectly referred to as the DD Form 7574-2 – was released by the Department of the Army in March 2008. A DA Form 7574-2 fillable version is available for e-filing and download below or can be found through the Army Publishing Directorate website.

The main purpose of the counseling is to ensure that the service member is fully aware of their rights and responsibilities. Mainly: being entitled to receive incapacitation pay that may not exceed full pay and allowances for the Soldier’s pay grade

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SOLDIER'S ACKNOWLEDGEMENT OF INCAPACITATION PAY COUNSELING
For use of this form, see DA PAM 135-381; the proponent agency is DCS, G-1.
(TO BE COMPLETED BY SOLDIER AND WITNESSED BY COMMANDER (See NOTE below))
I,
request incapacitation pay. I fully understand and agree to the following:
(Printed name and rank)
1. That this claim for incapacitation pay cannot be processed if proper documentation is not provided by me.
2. Any payments may be reduced by reportable earned income received from any other source.
3. That I may have to repay any monies received if a later determination is made that I was not entitled to them.
4. That if I am determined unfit for military duty, I WILL NOT perform Inactive Duty Training (drills) or Annual Training or any other form of active duty
during the period of time I am drawing incapacitation pay. This may result in my not earning a qualifying (good) year for retirement purposes. My
unit will assist me if requested for other ways to earn points.
5. That I must receive written or verbal authorization from a military medical facility or authorized government representative BEFORE obtaining
medical treatment from any civilian source or that I will be personally responsible for any charges incurred.
6. That I must submit to all medical treatment and report for medical fitness examinations and that failure to do so can result in termination or a
deduction of incapacitation pay. It is my responsibility to provide all medical documentation to my unit following medical appointments associated
with my injury/illness/disease. Failure to submit all medical treatment documentation including reporting for medical examinations, Physical Therapy
or follow up appointments will cause a delay or cancellation of my extension of incapacitation pay.
7. That in signing this form I hereby voluntarily grant permission, in relevant part IAW the Privacy Act, 37 USC § 204 and 10 USC § 3013 to provide
the government with information regarding my nonmilitary "earned income" and employment status and all medical information related to the injury,
illness, or disease identified above for the purpose of substantiating the claim. I recognize that failure to provide this information will result in no
payment being made.
AS THE INDIVIDUAL MAKING THE CLAIM, I UNDERSTAND THAT I AM RESPONSIBLE
FOR THE ACCURACY OF THE INFORMATION PROVIDED.
I understand that failure to fulfill the above requirements may result in termination of my entitlements to pay and allowances and medical care for this
disability. In relevant part, the maximum penalty for knowingly making a false claim is imprisonment for 5 years and a fine. (18 USC § 287)
SOLDIER'S SIGNATURE/DATE:
WITNESSED BY:
(COMMANDER'S PRINTED NAME, RANK, SIGNATURE AND DATE)
(NOTE: Commander must witness and sign. At JFHQ/USARC/RRC/MSC/UNIT level, the commander or individuals with "FOR THE
COMMANDER" signature authority may sign.)
DA Form 7574-2 must be completed and submitted with initial Incapacitation Pay
Monthly Claim Form (DA Form 7574)
PREVIOUS EDITION IS OBSOLETE.
DA FORM 7574-2, MAR 2008
APD LC V1.00

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

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How to File DA Form 7574-2?

An overview of the form and filing guidelines can be found in the Department of the Army Pamphlet 135–381, Incapacitation of Reserve Component Soldiers Processing Procedures, released in May 2008. DA Form 7574-2 instructions are as follows:

  1. If a soldier sustains any injuries, diseases or illnesses that result in an inability to perform military duties or lead to a reduction or loss in non-military income they may initiate an incapacitation pay claim.
  2. The soldier should promptly notify the first line leader and unit commander of the injury or illness. They, in turn, should immediately ensure that appropriate medical care is provided to the soldier and notify the next higher headquarters of the case.
  3. Next, the unit commander or the authorized representative counsel the soldier to read and sign the DA 7574-2. The form must be completed by the soldier and witnessed by their commander.
  4. The form lists seven conditions for receiving incapacitation pay. The soldier must read them and certify their agreement by providing their name, signature, and date of signing on the form. By signing, the soldier takes full responsibility to provide detailed and accurate information about their case.
  5. To be valid, the form must also contain the name, rank, and signature of the soldier’s commander. The completed document is submitted along with the initial incapacitation pay monthly claim form

DA 7574-2 Related Forms

  1. DA Form 7574, Incapacitation Pay Monthly Claim Form, is a document used for claiming incapacitation pay. The data provided within the DA 7574 is used to determine the soldier’s eligibility for any payments.
  2. DA Form 7574-1, Military Physician's Statement of Soldier's Incapacitation/Fitness For Duty, contains information necessary to verify soldier’s eligibility for military duties after an injury or illness.

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