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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 121 (Larceny or wrongful appropriation) of the Uniform Code Of Military Justice in that on or about(date) at
(location) you wrongfully appropriated(what property? What happened?________________) for your personal use.
                                                                    PART III - SUMMARY OF COUNSELING
                                       Complete this section during or immediately subsequent to the counseling

Key Points of Discussion:

Stealing is a crime and it is unacceptable behavior that will not be tolerated. If found guilty of this offense, the maximum
punishment is______________________. As a member of the United States Military you are expected to conduct yourself
in a professional manner and abide by the moral values that make our military the best in the world. Your misconduct has
been detrimental to the morale and discipline of this unit and it has resulted in the loss of confidence in you by the
members of this organization. (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 Counseling for violation of Article 121
Larceny and wrongful appropriation of the UCMJ. Requires Pure edge viewer
Army Counseling Statement, Article 121 Larceny and wrongful appropriation: Any member of the armed forces who,
wrongfully takes, obtains, or withholds, by any means, from the possession of the owner or of any other person any money,
personal property, or article of value of any kind ; may be punished under article 121.
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