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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