DA Form 4991 Declination of Continued Service Statement

DA Form 4991 or the "Declination Of Continued Service Statement" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 4991 - was last revised on March 1, 2016. Download an up-to-date fillable DA Form 4991 down below in PDF-format or look it up on the Army Publishing Directorate website.

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DECLINATION OF CONTINUED SERVICE STATEMENT
For use of this form, see AR 601-280; the proponent agency is DCS, G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AR 601-280 and Executive Order 9397 (SSN) as amended.
AUTHORITY:
For Soldier's election for commitment of additional service for operational assignment. This information becomes part of the
PRINCIPAL
subject's military personnel records which are used to document personnel management actions. The purpose of soliciting
PURPOSE:
the SSN is for positive identification.
ROUTINE USES:
The DoD Blanket Routine Uses that appear at the beginning of the Army's compilation of systems of records may apply to
this system.
DISCLOSURE:
Voluntary; however, failure to furnish information requested will may delay processing the action.
1. Name (Last, First, Middle)
2. Rank
3. SSN:
4. Unit/Organization
5. ETS
6. Assignment Report Date
7. You have incurred a service remaining requirement under the provisions of Chapter 4, AR 601-280 as a result of:
8. In order to comply with the service remaining requirement you must have
months remaining in service from your assignment report date.
(PMOS 79S)
SECTION A - COUNSELING BY THE CAREER COUNSELOR
9. The Soldier has been advised as to the options available to acquire sufficient remaining service to satisfy the commitment, but has refused
to take necessary action to meet the length of service. Soldier has been advised that refusal to take action to comply with the operational
commitment will have the following effects:
Initials
(The Soldier will initial in the space provided next to all career effects signifying understanding of that statement.)
a. I understand that I have no later than 45 days from the EDAS transmittal date to extend, reenlist or execute this statement.
b. I understand that I will be placed in a non promotable status.
c. I understand that I will be prohibited from reenlistment or extension of enlistment at a later date.
d. I understand that I will be removed from promotion standing list (if applicable).
e. I understand that I am prohibited from applying for reentry into the Active Army for a period of at least 93 days if separated at
current ETS, and at least 2 years if voluntarily separated before current ETS.
f. I understand that I am required to receive a grade determination from HQDA, if approved for reentry into the Active Army.
g. I understand that I am prohibited from application, election, or attendance for commissioning or warrant officer programs while on
the current period of active duty.
h. I understand that I am precluded from consideration by HQDA for centralized selection for promotion and/or advanced schooling.
i. I understand that I may be eligible to request voluntary separation under the provisions of AR 635-200.
j. I understand that I may be eligible to join the Reserve Component.
k. I understand that I may be considered eligible for other assignments (CONUS and OCONUS) provided I have sufficient
service remaining to meet the requirements of the new assignment.
l. I understand that I am not eligible for separation pay.
10a. Name, Rank and Unit of Career Counselor (PMOS 79S)
b. Place where the Soldier was advised
d. Date
c. Signature
SECTION B - SOLDIER'S ACKNOWLEDGEMENT OF COUNSELING
11. I hereby acknowledge that I have been counseled by the above career counselor concerning action required by me to satisfy a length-of-
service requirement incident to an operational commitment, and regarding my refusal to extend my enlistment or reenlist to comply with the
commitment. I understand the effects my refusal will have on my Army career and on any future decision I might make concerning reenlistment
or enlistment after separation.
a. Soldier's Signature
b. Date
12. If Soldier refuses to sign acknowledgment of counseling received, complete 12a, 12b and 12c below.
b. SIGNATURE
a. Name, Rank of Witness
c. DATE
SECTION C - IMMEDIATE COMMANDER'S/FIRST SERGEANT'S REVIEW
13. I have reviewed and discussed the above statement with the Soldier and have determined that the Soldier has been properly counseled. The
Soldier refused to take action to acquire sufficient service to comply with the operational commitment.
a. Name, Rank, and Branch of Commander/First Sergeant
b. Signature
c. Date
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.00ES
DA FORM 4991, MAR 2016
DECLINATION OF CONTINUED SERVICE STATEMENT
For use of this form, see AR 601-280; the proponent agency is DCS, G-1.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AR 601-280 and Executive Order 9397 (SSN) as amended.
AUTHORITY:
For Soldier's election for commitment of additional service for operational assignment. This information becomes part of the
PRINCIPAL
subject's military personnel records which are used to document personnel management actions. The purpose of soliciting
PURPOSE:
the SSN is for positive identification.
ROUTINE USES:
The DoD Blanket Routine Uses that appear at the beginning of the Army's compilation of systems of records may apply to
this system.
DISCLOSURE:
Voluntary; however, failure to furnish information requested will may delay processing the action.
1. Name (Last, First, Middle)
2. Rank
3. SSN:
4. Unit/Organization
5. ETS
6. Assignment Report Date
7. You have incurred a service remaining requirement under the provisions of Chapter 4, AR 601-280 as a result of:
8. In order to comply with the service remaining requirement you must have
months remaining in service from your assignment report date.
(PMOS 79S)
SECTION A - COUNSELING BY THE CAREER COUNSELOR
9. The Soldier has been advised as to the options available to acquire sufficient remaining service to satisfy the commitment, but has refused
to take necessary action to meet the length of service. Soldier has been advised that refusal to take action to comply with the operational
commitment will have the following effects:
Initials
(The Soldier will initial in the space provided next to all career effects signifying understanding of that statement.)
a. I understand that I have no later than 45 days from the EDAS transmittal date to extend, reenlist or execute this statement.
b. I understand that I will be placed in a non promotable status.
c. I understand that I will be prohibited from reenlistment or extension of enlistment at a later date.
d. I understand that I will be removed from promotion standing list (if applicable).
e. I understand that I am prohibited from applying for reentry into the Active Army for a period of at least 93 days if separated at
current ETS, and at least 2 years if voluntarily separated before current ETS.
f. I understand that I am required to receive a grade determination from HQDA, if approved for reentry into the Active Army.
g. I understand that I am prohibited from application, election, or attendance for commissioning or warrant officer programs while on
the current period of active duty.
h. I understand that I am precluded from consideration by HQDA for centralized selection for promotion and/or advanced schooling.
i. I understand that I may be eligible to request voluntary separation under the provisions of AR 635-200.
j. I understand that I may be eligible to join the Reserve Component.
k. I understand that I may be considered eligible for other assignments (CONUS and OCONUS) provided I have sufficient
service remaining to meet the requirements of the new assignment.
l. I understand that I am not eligible for separation pay.
10a. Name, Rank and Unit of Career Counselor (PMOS 79S)
b. Place where the Soldier was advised
d. Date
c. Signature
SECTION B - SOLDIER'S ACKNOWLEDGEMENT OF COUNSELING
11. I hereby acknowledge that I have been counseled by the above career counselor concerning action required by me to satisfy a length-of-
service requirement incident to an operational commitment, and regarding my refusal to extend my enlistment or reenlist to comply with the
commitment. I understand the effects my refusal will have on my Army career and on any future decision I might make concerning reenlistment
or enlistment after separation.
a. Soldier's Signature
b. Date
12. If Soldier refuses to sign acknowledgment of counseling received, complete 12a, 12b and 12c below.
b. SIGNATURE
a. Name, Rank of Witness
c. DATE
SECTION C - IMMEDIATE COMMANDER'S/FIRST SERGEANT'S REVIEW
13. I have reviewed and discussed the above statement with the Soldier and have determined that the Soldier has been properly counseled. The
Soldier refused to take action to acquire sufficient service to comply with the operational commitment.
a. Name, Rank, and Branch of Commander/First Sergeant
b. Signature
c. Date
PREVIOUS EDITIONS ARE OBSOLETE
APD LC v1.00ES
DA FORM 4991, MAR 2016

Download DA Form 4991 Declination of Continued Service Statement

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