"Request Form for DD 214" - Mississippi

Request Form for DD 214 is a legal document that was released by the Mississippi State Veterans Affairs Board - a government authority operating within Mississippi.

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Download "Request Form for DD 214" - Mississippi

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REQUEST FOR DD214
Generally the Mississippi Open Records Act permits access to a variety of information. However, such access is denied
when it would be contrary to any State or Federal statute or regulation. (Miss. Code Ann., Section 25-61-11 (1972)).
Although the Mississippi State Veterans Affairs Board is authorized to maintain the DD 214’s of members of the
military, who have separated from service, federal law restricts access to such personnel, medical or similar files.
Copies of DD 214’s are available to Veterans and next-of-kin of deceased Veterans. Next-of Kin are the widow or
widower, son or daughter, father or mother, brother or sister of the deceased Veteran. Authorized third party
requestors, e.g., lawyers, doctors, historians, etc., must submit request for copies of a DD 214 from individual records
with the Veteran’s (or next-of-kin’s) signed and dated authorization.
1. NAME USED DURING SERVICE (last, first and middle)
2. SOCIAL SECURITY NO.
3. DATE OF BIRTH
4. PLACE OF BIRTH
5. SERVICE NO.
6. BRANCH OF SERVICE
7. DATE OF SERVICE
(date entered, date released)
8. HOME OF RECORD ON DISCHARGE
9. IS THIS PERSON DECEASED? If “YES” enter the date of death.
NO
YES _________________________________
PERSON REQUESTING DOCUMENT:
PLEASE SEND DOCUMENT TO:
Name:_______________________________________
Name:__________________________________
Address:_____________________________________
Address:________________________________
_____________________________________
________________________________
Daytime Telephone:____________________________
Phone:__________________________________
Relationship to veteran (if veteran is deceased)
Fax:____________________________________
____________________________________________
Email:__________________________________
(surviving spouse, child, parent, sibling)
Must present proof by either: birth certificate,
marriage license, death certificate, power of
attorney or conservatorship, or published obituary.
AUTHORIZATION
I hereby authorize the Mississippi State Veterans Affairs Board to release the requested information. I
further state that all information I have provided on this form is true and accurate to the best of my
knowledge.
Signature of Requestor
Date
STATE VETERANS AFFAIRS BOARD, 3466 HWY. 80 EAST P.O. BOX 5947 PEARL, MS 39288-5947
PHONE:(601)576-4850 FAX: (601)576-4870
REQUEST FOR DD214
Generally the Mississippi Open Records Act permits access to a variety of information. However, such access is denied
when it would be contrary to any State or Federal statute or regulation. (Miss. Code Ann., Section 25-61-11 (1972)).
Although the Mississippi State Veterans Affairs Board is authorized to maintain the DD 214’s of members of the
military, who have separated from service, federal law restricts access to such personnel, medical or similar files.
Copies of DD 214’s are available to Veterans and next-of-kin of deceased Veterans. Next-of Kin are the widow or
widower, son or daughter, father or mother, brother or sister of the deceased Veteran. Authorized third party
requestors, e.g., lawyers, doctors, historians, etc., must submit request for copies of a DD 214 from individual records
with the Veteran’s (or next-of-kin’s) signed and dated authorization.
1. NAME USED DURING SERVICE (last, first and middle)
2. SOCIAL SECURITY NO.
3. DATE OF BIRTH
4. PLACE OF BIRTH
5. SERVICE NO.
6. BRANCH OF SERVICE
7. DATE OF SERVICE
(date entered, date released)
8. HOME OF RECORD ON DISCHARGE
9. IS THIS PERSON DECEASED? If “YES” enter the date of death.
NO
YES _________________________________
PERSON REQUESTING DOCUMENT:
PLEASE SEND DOCUMENT TO:
Name:_______________________________________
Name:__________________________________
Address:_____________________________________
Address:________________________________
_____________________________________
________________________________
Daytime Telephone:____________________________
Phone:__________________________________
Relationship to veteran (if veteran is deceased)
Fax:____________________________________
____________________________________________
Email:__________________________________
(surviving spouse, child, parent, sibling)
Must present proof by either: birth certificate,
marriage license, death certificate, power of
attorney or conservatorship, or published obituary.
AUTHORIZATION
I hereby authorize the Mississippi State Veterans Affairs Board to release the requested information. I
further state that all information I have provided on this form is true and accurate to the best of my
knowledge.
Signature of Requestor
Date
STATE VETERANS AFFAIRS BOARD, 3466 HWY. 80 EAST P.O. BOX 5947 PEARL, MS 39288-5947
PHONE:(601)576-4850 FAX: (601)576-4870