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                                     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)
Rank/Grade
Social Security No.
Date of Counseling
Organization
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
Download and make changes to DA Form 4856 Army Counseling for violation of Article 107
False statements of the UCMJ. Requires Pure edge viewer
Arny Counseling Example, 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.
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Making false statements on Official Military Documents is a Crime and can get you on PCS Orders to Prison very
fast. This Counseling Statement is used for the Soldier that writes him or herself a physical profile to get out of
duty or physical training and other similar offences. If your Soldier has knowingly provided false information with
intent to commit fraud against the government then it is too late for counseling as the Soldier will be investigated
by CID and likely go to prison.
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