"Request Form for DD 214" - Mississippi

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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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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.

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