DA Form 5811 Certificate - Lost or Damaged Class 5 Ammunition Items

DA Form 5811 - also known as the "Certificate - Lost Or Damaged Class 5 Ammunition Items" - 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 5811 - was last revised on June 1, 2004. Download an up-to-date fillable PDF version of the DA 5811 below or request a copy through the chain of command.

ADVERTISEMENT
CERTIFICATE - LOST OR DAMAGED CLASS 5 AMMUNITION ITEMS
For use of this form, see DA PAM 710-2-1; the proponent agency is DCS, G-4.
PART I - CERTIFICATION
I certify that the item(s) described in blocks 1-5 below were as stated. Circumstances of the loss or damage are accurately
described below.
5 DAMAGED BY
4. ITEM WAS (Check)
1.
2.
3.
NEGLIGENCE? (Check)
a. LOST
b. DAM-
STOCK NO.
DESCRIPTION
QUANTITY
a YES
b NO
AGED
6.
CIRCUMSTANCES OF LOSS OR DAMAGE
7a. SIGNATURE
7b. DATE
PART II - ACTION
8. I have reviewed the evidence pertaining to the loss or damage as stated. I agree
do not agree
that the loss or damage to the class 5 item (s) was
was not
due to negligence, willful
misconduct, or deliberate unauthorized use. The following actions shall be taken.
CHECK ALL THAT APPLY
9.
No further action is required.
10.
An administrative adjustment shall be made in the property book for the class 5 item (s) that were not lost through
negligence, willful misconduct, or deliberate unauthorized use.
11.
The damaged class 5 item(s) shall be repaired as fair wear and tear as the damage was not caused by negligence,
willful misconduct, or deliberate unauthorized use.
12.
The circumstances surrounding the loss or damage warrant the processing of a formal Report or Survey that will
be initiated immediately by the responsible property officer.
13a. SIGNATURE
13b. TITLE
13c. DATE
DA FORM 5811, JUN 2004
APD LC v1.00ES
CERTIFICATE - LOST OR DAMAGED CLASS 5 AMMUNITION ITEMS
For use of this form, see DA PAM 710-2-1; the proponent agency is DCS, G-4.
PART I - CERTIFICATION
I certify that the item(s) described in blocks 1-5 below were as stated. Circumstances of the loss or damage are accurately
described below.
5 DAMAGED BY
4. ITEM WAS (Check)
1.
2.
3.
NEGLIGENCE? (Check)
a. LOST
b. DAM-
STOCK NO.
DESCRIPTION
QUANTITY
a YES
b NO
AGED
6.
CIRCUMSTANCES OF LOSS OR DAMAGE
7a. SIGNATURE
7b. DATE
PART II - ACTION
8. I have reviewed the evidence pertaining to the loss or damage as stated. I agree
do not agree
that the loss or damage to the class 5 item (s) was
was not
due to negligence, willful
misconduct, or deliberate unauthorized use. The following actions shall be taken.
CHECK ALL THAT APPLY
9.
No further action is required.
10.
An administrative adjustment shall be made in the property book for the class 5 item (s) that were not lost through
negligence, willful misconduct, or deliberate unauthorized use.
11.
The damaged class 5 item(s) shall be repaired as fair wear and tear as the damage was not caused by negligence,
willful misconduct, or deliberate unauthorized use.
12.
The circumstances surrounding the loss or damage warrant the processing of a formal Report or Survey that will
be initiated immediately by the responsible property officer.
13a. SIGNATURE
13b. TITLE
13c. DATE
DA FORM 5811, JUN 2004
APD LC v1.00ES

Download DA Form 5811 Certificate - Lost or Damaged Class 5 Ammunition Items

877 times
Rate
4.3(4.3 / 5) 209 votes
ADVERTISEMENT