b. DA Form 3983 (Patients' Trust Fund - Authorization for Deposit or
Withdrawal of Funds and Valuables). See figure 5-4.
General. This form is prepared in duplicate for every deposit or
withdrawal of funds and valuables (other than the initial deposit) requiring the services of an
intermediate recipient except where the Military Payroll Money List is used for deposits or
a roster of patients is used for purchase of comfort items.
Withdrawals. When the patient is physically unable to go to the
custodian's office to make a withdrawal, DA Form 3983 is prepared in duplicate and
signed by the patient. The duplicate is retained by the patient. The original, together with
the patient's copy of the deposit record, are presented to the custodian by the
intermediate individual for payment. The custodian verifies the patient's signature on the
DA form 3983 and makes the proper entries on both copies of the deposit record. The
intermediate individual signs both copies of the deposit record and returns the money or
valuables, together with the patient's copy of the deposit record, to the patient. The
intermediate individual signs for money or valuables on the original DA Form 3983 which is
returned by the custodian. The duplicate DA Form 3983 is signed by the patient upon
delivery of the money or valuables and given to the intermediate individual as his receipt.
When a patient is physically unable to sign the necessary forms, the above procedure is
followed except that the signature of a witness is secured in lieu of that patient.
Deposits. When the patient is physically unable to go to the custodian's
office, DA Form 3983 is prepared in duplicate and both copies are signed by the patient.
The duplicate is signed by the intermediate individual and retained by the patient until the
transaction is completed. The original, together with the additional funds and/or valuables
and the patient's copy of the deposit record, are taken to the custodian by the intermediate
individual. The custodian makes the appropriate entries on both copies of the deposit
card, signs both copies, and returns the patient's copy to the intermediate individual for
delivery to the patient. The original DA Form 3983 is retained by the custodian; the
duplicate is returned to the intermediate individual by the patient upon delivery of his copy
of the deposit record. When the patient's signature cannot be obtained, DA Form 3696 or
DA Form 3982, as appropriate, is signed by a witness as described for a withdrawal.