DA Form 4916 Certificate of Service/Attempted Service

DA Form 4916 - also known as the "Certificate Of Service/attempted Service" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 4916 - was last revised on June 1, 2009. Download an up-to-date fillable PDF version of the DA 4916 below or request a copy through the chain of command.

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CERTIFICATE OF SERVICE/ATTEMPTED SERVICE
For use of this form, see AR 27-10; the proponent agency is OTJAG.
UNIT AND INSTALLATION
DATE (YYYYMMDD)
COMPLETE APPLICABLE SECTION BELOW
SECTION A - CERTIFICATE OF SERVICE
day of
,
, I served a copy of the decision of the United
I hereby certify that on the
States Army Court of Criminal Appeals (ACCA) on the accused in the case of the United States v.
,
(Name)
. At the time of service the accused was advised of his or her
(ACMR Docket No.)
right to petition the United States Court of Appeals for the Armed Forces (USCAAF) by mailing five (5) copies of the Petition for Grant of Review
to the Court at 450 E Street, NW, Washington, DC 20442, prior to the lapse of sixty (60) days from the date he or she was notified of the decision
of the ACCA.
TYPED NAME & GRADE OF SJA REPRESENTATIVE OR DESIGNEE
SIGNATURE
SECTION B - CERTIFICATE OF ATTEMPTED SERVICE (IN PERSON)
I hereby certify that on the
day of
,
, I attempted to serve a copy of the decision of
the United States Army Court of Criminal Appeals on the accused in the case of the United States v.
(Name)
,
, and was unable to do so. The accused
(ACCA Docket No.)
(absented himself without authority) (escaped from confinement) (
) on the
day of
,
.
NOTE: A copy of the pertinent DA Form 4187 is attached.
TYPED NAME & GRADE OF SJA REPRESENTATIVE OR DESIGNEE
SIGNATURE
SECTION C - CERTIFICATE OF ATTEMPTED SERVICE (BY MAIL)
,
, I placed a copy of the decision of the United
1. I hereby certify that on the
day of
States Court of Criminal Appeals, together with a copy of the attached DA Form 4917 advising the accused of his or her right to petition
the United States Court of Appeals for the Armed Forces in the case of the United States v.
,
, in an
(Name)
(ACCA Docket No.)
envelope addressed to him or her at
,
said envelope being marked "Certified Mail, Return Receipt Requested," that the envelope was placed in military channels
for delivery to the Postal Service to be dispatched "Certified Mail" in accordance with the instructions on the envelope.
The above address (was provided by the accused) (was not provided by the accused and is the most recent address listed
in the accused's official military personnel records). [Cross out the phrase which does not apply.]
(On the
day of
,
, I received the attached Return Receipt from
2a.
day of
,
.)
the Postal Service which shows that delivery was made on the
(On the
day of
,
, I received the attached Return Receipt from
b.
the Postal Service for the aforementioned communication and the attached envelope and its contents, and the said envelope
is marked as undeliverable by the Postal Service.)
(As of the
day of
,
, 65 days having passed since the date of
c.
postmark, I have received no communication concerning the delivery of the certified envelope and its contents.)
TYPED NAME & GRADE OF SJA REPRESENTATIVE OR DESIGNEE
SIGNATURE
DA FORM 4916, JUN 2009
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.00ES
CERTIFICATE OF SERVICE/ATTEMPTED SERVICE
For use of this form, see AR 27-10; the proponent agency is OTJAG.
UNIT AND INSTALLATION
DATE (YYYYMMDD)
COMPLETE APPLICABLE SECTION BELOW
SECTION A - CERTIFICATE OF SERVICE
day of
,
, I served a copy of the decision of the United
I hereby certify that on the
States Army Court of Criminal Appeals (ACCA) on the accused in the case of the United States v.
,
(Name)
. At the time of service the accused was advised of his or her
(ACMR Docket No.)
right to petition the United States Court of Appeals for the Armed Forces (USCAAF) by mailing five (5) copies of the Petition for Grant of Review
to the Court at 450 E Street, NW, Washington, DC 20442, prior to the lapse of sixty (60) days from the date he or she was notified of the decision
of the ACCA.
TYPED NAME & GRADE OF SJA REPRESENTATIVE OR DESIGNEE
SIGNATURE
SECTION B - CERTIFICATE OF ATTEMPTED SERVICE (IN PERSON)
I hereby certify that on the
day of
,
, I attempted to serve a copy of the decision of
the United States Army Court of Criminal Appeals on the accused in the case of the United States v.
(Name)
,
, and was unable to do so. The accused
(ACCA Docket No.)
(absented himself without authority) (escaped from confinement) (
) on the
day of
,
.
NOTE: A copy of the pertinent DA Form 4187 is attached.
TYPED NAME & GRADE OF SJA REPRESENTATIVE OR DESIGNEE
SIGNATURE
SECTION C - CERTIFICATE OF ATTEMPTED SERVICE (BY MAIL)
,
, I placed a copy of the decision of the United
1. I hereby certify that on the
day of
States Court of Criminal Appeals, together with a copy of the attached DA Form 4917 advising the accused of his or her right to petition
the United States Court of Appeals for the Armed Forces in the case of the United States v.
,
, in an
(Name)
(ACCA Docket No.)
envelope addressed to him or her at
,
said envelope being marked "Certified Mail, Return Receipt Requested," that the envelope was placed in military channels
for delivery to the Postal Service to be dispatched "Certified Mail" in accordance with the instructions on the envelope.
The above address (was provided by the accused) (was not provided by the accused and is the most recent address listed
in the accused's official military personnel records). [Cross out the phrase which does not apply.]
(On the
day of
,
, I received the attached Return Receipt from
2a.
day of
,
.)
the Postal Service which shows that delivery was made on the
(On the
day of
,
, I received the attached Return Receipt from
b.
the Postal Service for the aforementioned communication and the attached envelope and its contents, and the said envelope
is marked as undeliverable by the Postal Service.)
(As of the
day of
,
, 65 days having passed since the date of
c.
postmark, I have received no communication concerning the delivery of the certified envelope and its contents.)
TYPED NAME & GRADE OF SJA REPRESENTATIVE OR DESIGNEE
SIGNATURE
DA FORM 4916, JUN 2009
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.00ES

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