DD Form 577, Appointment/Termination Record Authorized Signature, November 2014 DD409S Dd0577

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APPOINTMENT/TERMINATION RECORD - AUTHORIZED SIGNATURE
(Read Privacy Act Statement and Instructions before completing form.)

PRIVACY ACT STATEMENT
AUTHORITY: E.O. 9397, 31 U.S.C. Sections 3325, 3528, DoDFMR, 7000.14-R, Vol. 5.
PRINCIPAL PURPOSE(S): To maintain a record of appointment and termination of appointment of persons to any of the positions listed in Item 6,
and to identify the duties associated with this appointment.
SORN T1300 (http://dpclo.defense.gov/Pricacy/SORNsIndex/DODComponentArticleView/tabid/7489/Article/6235/t1300.aspx)
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C Section 552a(b) of the Privacy Act of 1974,
as amended. It may also be disclosed outside of the Department of Defense (DoD) to the Federal Reserve Banks to verify authority of the appointed
individuals to issue Treasury checks. In addition, other Federal, State and local government agencies, which have identified a need to know, may
obtain this information for the purpose(s) identified in the DoD Blanket Routine Uses published at:
http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.
DISCLOSURE Voluntary; however, failure to provide the requested information may preclude appointments.

SECTION I - APPOINTEE
1. NAME (First, Middle Initial, Last and Rank or Grade)

2. DoD ID NUMBER

3. TITLE

4. DOD COMPONENT/ORGANIZATION

5. ADDRESS (Include ZIP Code, email address, and telephone number with area code and DSN)

6. POSITION TO WHICH APPOINTED (X appropriate box - one only. Checking more than one invalidates the appointment.)
DISBURSING OFFICER: DSSN
CASHIER
CHANGE FUND CUSTODIAN
DEPUTY DISBURSING OFFICER: DSSN
PAYING AGENT
IMPREST FUND CASHIER
CERTIFYING OFFICER
SAFEKEEPING CUSTODIAN
COLLECTIONS AGENT
DEPARTMENTAL ACCOUNTABLE OFFICIAL
ASSISTANT SAFEKEEPING CUSTODIAN
DISBURSING AGENT
7. YOU ARE APPOINTED TO SERVE IN THE POSITION IDENTIFIED IN ITEM 6. YOUR RESPONSIBILITIES INCLUDE:

8. REVIEW AND ADHERE TO THE FOLLOWING PUBLICATION(S) NEEDED TO ADEQUATELY PERFORM YOUR ASSIGNED DUTIES:

SECTION II - APPOINTING AUTHORITY
9. NAME (First, Middle Initial, Last)

10. TITLE

12. DATE (YYYYMMDD)

13. SIGNATURE

11. DOD COMPONENT/ORGANIZATION

SECTION III - APPOINTEE ACKNOWLEDGEMENT
I acknowledge and accept the position and responsibilities defined above. I understand that I am strictly liable to the United
States for all public funds or payment certification, as appropriate, under my control. I have been counseled on my pecuniary liability
applicable to this appointment and have been given written operating instructions. I certify that my official signature is shown in item
16 below.
14. PRINTED NAME (First, Middle Initial, Last)

15. DATE (YYYYMMDD) (Not earlier than date in Item 12 or 13)

16.a. DIGITAL SIGNATURE

16.b. MANUAL SIGNATURE

SECTION IV - APPOINTMENT TERMINATION
17. DATE (YYYYMMDD)

The appointment of the individual named above is
hereby revoked.
19. NAME OF APPOINTING AUTHORITY

DD FORM 577, NOV 2014

20. TITLE

18. APPOINTEE INITIALS

21. APPOINTING AUTHORITY SIGNATURE

PREVIOUS EDITION IS OBSOLETE.

Adobe Designer 9.0

INSTRUCTIONS FOR COMPLETING
APPOINTMENT/TERMINATION RECORD - AUTHORIZED SIGNATURE
Use this form to:
1. Appoint disbursing officers and their agents, e.g., deputy disbursing officers, disbursing agents, paying agents, cashiers,
imprest fund cashiers, change fund custodians, and collection agents.
2. Appoint certifying officers. Certifying officers are those individuals, military or civilian, designated to attest to the correctness
of statements, facts, accounts, and amounts appearing on a voucher for payment.
3. Appoint departmental officials. Departmental officials are those individuals, military or civilian, who are designated in writing
and are not otherwise accountable under applicable law, who provide source information, data or service on which a
certifying officer relies when certifying vouchers as correct and proper for payment.
4. Appoint safekeeping custodians or assistants. Appointees to these positions are not subject to pecuniary liability.
5. Governing guidance is in the Department of Defense Financial Management Regulation, Volume 5 (Disbursing Policy).
SECTION I.
1. Enter the Appointee's name and rank or grade.
2. Enter the Appointee's 10-digit DoD Identification Number.
3. Enter the Appointee's title.
4. - 5. Enter the name, complete address (to include e-mail address), and telephone number (include DSN when available)
of the DoD Component or activity to which appointed.
6. Mark X in the appropriate box to indicate the duty the appointee will perform (select only one). If appointing a disbursing
officer or deputy disbursing officer, enter the appropriate DSSN in the space provided.
7. The appointing authority identifies the types of payments affected, but need only be specific as he or she considers
necessary, and may include any other pertinent, applicable information (e.g., system involved).
8. List all publications the Appointee must review and follow in order to adequately fulfill the requirements of the appointment.
SECTION II.
9. - 12. Enter the appointing authority's name, title, DoD Component/Organization location, and date signed.
13. The appointing authority must enter his or her manual or digital signature. If signature is digital, completing item 12 is not
required since the digital signature includes the date; enter only after completion of items 1 through 11, as this signature
will "lock" those items.
SECTION III.
14. - 16. The appointee enters his or her name and digital (16a) or manual (16b) signature, or both, depending on type(s) of
signature(s) to be employed, in the appropriate spaces. If the signature is manual (16b), complete item 15, but if the
signature is ONLY digital (16a), completing item 15 is not required since the digital signature includes the date. If the
appointee enters both manual and digital signatures, the dates in items 15 and 16a must match. The date in item 15
(or 16a if signed digitally) cannot be earlier than the date in item 12 or 13. The appointment is effective on the date of
acceptance by the appointee, and is not in force without his or her acknowledgement.
SECTION IV.
Completing this section terminates the original appointment. If partial authority is to be retained, complete a new DD Form 577.
17. Enter the date the termination is effective. Completion of this item is not required if item 21 is signed digitally, since the
electronic signature includes the date.
18. The appointee initials in the space provided acknowledging revocation of the appointment.
19. - 21. The appointing authority enters his or her name, title and signature (which may be digital) in the spaces provided.

DD FORM 577 (BACK), NOV 2014
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Title                           : DD Form 577, Appointment/Termination Record - Authorized Signature, November 2014
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