| DEVELOPMENTAL COUNSELING FORM
For use this form see FM 22-100
| DATA REQUIRED BY THE PRIVACY ACT OF 1974
|AUTHORITY: 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397 (SSN)
PRINCIPAL PURPOSE: To assist leaders in conducting and recording counseling data pertaining to subordinates
ROUTINE USES: For subordinate leader development IAW FM 22-100 leaders should use this form as necessary
DISCLOSURE: Disclosure is voluntary
| PART I - ADMINISTRATIVE DATA
|Name (Last, First, MI)
||Social Security No.
||Date of Counseling
||Name and Title of Counselor
| PART II - BACKGROUND INFORMATION
|Purpose of Counseling: (Leader states the reason for the counseling, e.g. Performance/Professional or Event-Oriented counseling and includes the leaders facts
and observations prior to the counseling)
Event-Oriented: Violation of article 107 (false statements) of the Uniform Code Of Military Justice in that on or about (date) at (location) you
made a false statement, to(what happened? Describe in detail).
| PART III - SUMMARY OF COUNSELING
Complete this section during or immediately subsequent to the counseling
Key Points of Discussion:
In the United States Military, making a false official statement is a criminal offense and it is unacceptable behavior that will
not be tolerated. If found guilty of this offense, the maximum punishment is ______________________. False and
misleading information jeopardises the effectiveness of our organization to successfully accomplish the missions at hand.
Your misconduct has been detrimental to unit morale and the discipline of this organization and will not be repeated. (I am
recommending that the commander impose nonjudicial punishment for your misconduct) OR (You will receive corrective
training as outlined in the plan of action).
You are here by notified that if this type of conduct continues, actions may be initiated under the Uniform Code of Military
Justice to separate you from the Army prior to your scheduled ETS Date IAW AR 635-200. If you are involuntary
separated, you could receive an Honorable Discharge, a General (Under Honorable Conditions) Discharge, or a Under
Other Than Honorable Conditions Discharge. If you receive a discharge Under Other Than Honorable Conditions, you will
be ineligible for reenlistment and for most benefits, including payments of accrued leave, transitional benefits, the
Montgomery GI Bill, VA benefits, and You may also face difficulty in obtaining civilian employment.
| OTHER INSTRUCTIONS
This form will be destroyed upon reassignment (other than rehabilitative transfers), separations at ETS, or upon retirement. For separation requirements
and notification of loss of benefits/consequenses see local directives and AR 635-200
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|Counseling Statement Examples
|Article 107 False statements: Any member of the armed forces who, with intent to deceive, signs any false records, return, regulation, order,, or
other official document , knowing it to be false or makes any false official statements knowing it to be false, may be punished under article 107.