DA Form 5221-R "Child Development Services (Cds) Family Child Care (FCC) Certification, Denial/Revocation (Lra)"

What Is DA Form 5221-R?

This is a military form that was released by the U.S. Department of the Army (DA) on July 1, 1989. The form, often mistakenly referred to as the DD Form 5221-R, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 5221-R down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 5221-R "Child Development Services (Cds) Family Child Care (FCC) Certification, Denial/Revocation (Lra)"

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CHILD DEVELOPMENT SERVICES (CDS)
FAMILY CHILD CARE (FCC) CERTIFICATION DENIAL/REVOCATION
For use of this form, see AR 608-10; the proponent agency is DCSPER.
TO: (Applicant) (Name and Address) (Include ZIP Code)
FROM: (Issuing Office)
YOUR FCC HOME PROVIDER (Application for Certification) (Certification Document) HAS BEEN (disapproved) (revoked)
AT THIS TIME FOR THE FOLLOWING REASON (S)
FAILURE TO SUBMIT ALL REQUIRED INFORMATION/FORMS
FAILURE TO MEET FIRE PREVENTION AND PROTECTION REQUIREMENTS
FAILURE TO MEET SAFETY REQUIREMENTS
FAILURE TO MEET FACILITY REQUIREMENTS
FAILURE TO MEET DEVELOPMENTAL REQUIREMENTS
FAILURE TO MEET FOOD/NUTRITION REQUIREMENTS
FAILURE TO MEET HEALTH REQUIREMENTS
FAILURE TO PROVIDE SATISFACTORY BACKGROUND CLEARANCE REQUESTS
FAILURE TO ATTEND (Pre-certification) (on-going) TRAINING
FAILURE TO PROVIDE SATISFACTORY PROGRAM SERVICE
FAILURE TO PROVIDE NON-DISCRIMINATORY SERVICE
OTHER
CHECK APPROPRIATE BOX(ES) (Issuing Offices)
YOU MUST PROVIDE THE ADDITIONAL INFORMATION OR EVIDENCE THAT DEFICIENCIES HAVE BEEN MET, WITHIN 30
DAYS TO THE ISSUING OFFICE.
YOU ARE HEREBY OFFICIALLY NOTIFIED THAT YOUR (Certification Application) (Certification Document) is (denied) (revoked)
AND YOU MUST IMMEDIATELY DISCONTINUE ANY FORM OF CHILD CARE REGULATED BY AR 608-10. THE
CERTIFICATION DOCUMENT MUST BE RETURNED TO THE ISSUING OFFICE UNTIL CERTIFICATION HAS BEEN RESTORED.
REAPPLICATION FOR FCC CERTIFICATION MAY OCCUR AFTER A 30 DAY WAITING PERIOD AND WHEN A PROPONENT
AGENCY REPRESENTATIVE VERIFIES COMPLIANCE WITH THE DEFICIENCIES NOTED ABOVE.
SIGNATURE (CDS Coordinator)
SIGNATURE (Installation/Community Commander)
EDITION OF AUG 83 IS OBSOLETE.
DA FORM 5221-R, JUL 1989
APD LC v2.01ES
CHILD DEVELOPMENT SERVICES (CDS)
FAMILY CHILD CARE (FCC) CERTIFICATION DENIAL/REVOCATION
For use of this form, see AR 608-10; the proponent agency is DCSPER.
TO: (Applicant) (Name and Address) (Include ZIP Code)
FROM: (Issuing Office)
YOUR FCC HOME PROVIDER (Application for Certification) (Certification Document) HAS BEEN (disapproved) (revoked)
AT THIS TIME FOR THE FOLLOWING REASON (S)
FAILURE TO SUBMIT ALL REQUIRED INFORMATION/FORMS
FAILURE TO MEET FIRE PREVENTION AND PROTECTION REQUIREMENTS
FAILURE TO MEET SAFETY REQUIREMENTS
FAILURE TO MEET FACILITY REQUIREMENTS
FAILURE TO MEET DEVELOPMENTAL REQUIREMENTS
FAILURE TO MEET FOOD/NUTRITION REQUIREMENTS
FAILURE TO MEET HEALTH REQUIREMENTS
FAILURE TO PROVIDE SATISFACTORY BACKGROUND CLEARANCE REQUESTS
FAILURE TO ATTEND (Pre-certification) (on-going) TRAINING
FAILURE TO PROVIDE SATISFACTORY PROGRAM SERVICE
FAILURE TO PROVIDE NON-DISCRIMINATORY SERVICE
OTHER
CHECK APPROPRIATE BOX(ES) (Issuing Offices)
YOU MUST PROVIDE THE ADDITIONAL INFORMATION OR EVIDENCE THAT DEFICIENCIES HAVE BEEN MET, WITHIN 30
DAYS TO THE ISSUING OFFICE.
YOU ARE HEREBY OFFICIALLY NOTIFIED THAT YOUR (Certification Application) (Certification Document) is (denied) (revoked)
AND YOU MUST IMMEDIATELY DISCONTINUE ANY FORM OF CHILD CARE REGULATED BY AR 608-10. THE
CERTIFICATION DOCUMENT MUST BE RETURNED TO THE ISSUING OFFICE UNTIL CERTIFICATION HAS BEEN RESTORED.
REAPPLICATION FOR FCC CERTIFICATION MAY OCCUR AFTER A 30 DAY WAITING PERIOD AND WHEN A PROPONENT
AGENCY REPRESENTATIVE VERIFIES COMPLIANCE WITH THE DEFICIENCIES NOTED ABOVE.
SIGNATURE (CDS Coordinator)
SIGNATURE (Installation/Community Commander)
EDITION OF AUG 83 IS OBSOLETE.
DA FORM 5221-R, JUL 1989
APD LC v2.01ES