APPLICATION FOR CERTIFIED COPY OF MILITARY DISCHARGE

APPLICATION FOR CERTIFIED COPY OF MILITARY DISCHARGE
DD-214 Information:
Name of Veteran:
Last Name *
First*
Middle*
Discharge Date

MonthDayYear
Branch of Service
Date of Recording (if known)

MonthDayYear
Applicant Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Photo ID Type
ID #
To obtain a Certified Copy of a DD-214, you must be authorized under California Government Code Section 6107. Please check the appropriate line below:
Person who is subject of the recordFamily member or legal representative of person who is subject of the record (must present proper identification)County office that provides veteran's benefits (upon written request of that office)United States official (upon written request of that official)
I, Name swear under penalty of perjury that I am an authorized person, as defined in California Government Code Section 6107 and am eligible to receive a certified copy of the record identified on this application form. Sworn this Date day of Date,20 Date at Street Address Address Line 2 City State Zip
Your original signature is required. Please print this form using the Print PDF for Signature button and submit it in person to 3501 Civic Center Dr., Room 232, San Rafael, CA. If you are submitting by mail, sign the form in the presence of a Notary and have the Notary complete the Certificate of Acknowledgment.
Should be Empty:

APPLICATION FOR CERTIFIED COPY OF MILITARY DISCHARGE

DD-214 Information:

Name of Veteran:

Applicant Information: