Form IL497-0565 "Request and Consent to Release Information for Veteran's Records" - Illinois

What Is Form IL497-0565?

This is a legal form that was released by the Illinois Department of Veterans Affairs - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Illinois Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form IL497-0565 by clicking the link below or browse more documents and templates provided by the Illinois Department of Veterans Affairs.

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Download Form IL497-0565 "Request and Consent to Release Information for Veteran's Records" - Illinois

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ILLINOIS DEPARTMENT OF VETERANS’ AFFAIRS
833 SOUTH SPRING STREET
SPRINGFIELD, IL 62704
REQUEST AND CONSENT TO RELEASE INFORMATION FOR VETERAN’S RECORDS
RECORDS REQUEST
*
Indicates a Required Fields
I.
*Date
:_______________________
*
INFORMATION REQUESTED (Number each item requested and give the dates or approximate dates – period from and to – covered by each.
Discharge Records
Specific (Provide Dates): __________________________
All Discharges
Other __________________________
* PURPOSE (S) FOR WHICH THE INFORMATION IS TO BE USED.
State Employment
Benefit
: __________________________
Other
Replacement
VETERANS' INFORMATION
II.
*NAME OF VETERAN (Type or Print)
DEPARTMENT OF VETERANS’ AFFAIRS
833 SOUTH SPRING STREET (RECORDS SECTION)
TO
:
SPRINGFIELD, IL 62704
*SERVICE NO. (If Known)
*SOCIAL SECURITY NO. (If Known)
*DATE OF BIRTH (If Known)
FAX: (217) 782-4161
*BRANCH OF SERVICE
DATES OF SERVICE
HOME OF RECORD (City and State)
PHONE NUMBER OF VETERAN
*ADDRESS OF VETERAN (If Living)
(Street, City, State, Zip Code)
*EMAIL ADDRESS:
*VETERANS' SIGNATURE:
I hereby request and authorize the Illinois Department of Veterans’ Affairs to release the
following record(s) identified, in the “Records Request” section, to the organization, agency, or
individual named hereon. AS COVERED BY 330 ILCS 70/0.01 et. seq.
*NAME:
(Type or Print)
SEND TO THE ABOVE ADDRESS ALONG WITH A COPY OF A VALID FORM OF IDENTIFICATION
(i.e., Driver’s License, State ID, or Medicaid Card)
IF YOU ARE NOT THE VETERAN LISTED ABOVE, YOU WILL NEED TO MARK YOUR APPLICABLE CLASSIFICATION
III.
AND PROVIDE THE DOCUMENTATION FOR THAT CLASSIFICATION LISTED BELOW.
Photo ID required for proof of requesting individual
I am:
Spouse/Surviving Spouse – Marriage Certificate/Proof of Power of Attorney/Veteran’s Death Certificate.
Dependent Child – Birth Certificate/Adoption Decree, showing relationship to the veteran. Relationship_______________________
Guardian – Court Declaration of Guardianship.
Fiduciary – Court Declaration of Fiduciary responsibility.
Executor – Documentation signed by decedent/Probate Order appointing Executor.
Accredited Service Organization – Proof of Power of Attorney.(VFW, DAV, etc.)
Authorized Government Agency .
Any other pertinent legal document(s) to verify the above status.
*
Phone
WRITTEN INFORMATION MUST BE LEGIBLE
*
*Individual/Organization (if applicable)
Fax
*
*Street
*City
*State
*Zip
Email
*Name
*Signature
I attest that the information provided is accurate, and that I am the legal next-of-kin or authorized recipient of the requested document(s).
AS COVERED BY 330 ILCS 70/0.01 et. seq.
I
L 497-0565
REVISED 11/2020
ILLINOIS DEPARTMENT OF VETERANS’ AFFAIRS
833 SOUTH SPRING STREET
SPRINGFIELD, IL 62704
REQUEST AND CONSENT TO RELEASE INFORMATION FOR VETERAN’S RECORDS
RECORDS REQUEST
*
Indicates a Required Fields
I.
*Date
:_______________________
*
INFORMATION REQUESTED (Number each item requested and give the dates or approximate dates – period from and to – covered by each.
Discharge Records
Specific (Provide Dates): __________________________
All Discharges
Other __________________________
* PURPOSE (S) FOR WHICH THE INFORMATION IS TO BE USED.
State Employment
Benefit
: __________________________
Other
Replacement
VETERANS' INFORMATION
II.
*NAME OF VETERAN (Type or Print)
DEPARTMENT OF VETERANS’ AFFAIRS
833 SOUTH SPRING STREET (RECORDS SECTION)
TO
:
SPRINGFIELD, IL 62704
*SERVICE NO. (If Known)
*SOCIAL SECURITY NO. (If Known)
*DATE OF BIRTH (If Known)
FAX: (217) 782-4161
*BRANCH OF SERVICE
DATES OF SERVICE
HOME OF RECORD (City and State)
PHONE NUMBER OF VETERAN
*ADDRESS OF VETERAN (If Living)
(Street, City, State, Zip Code)
*EMAIL ADDRESS:
*VETERANS' SIGNATURE:
I hereby request and authorize the Illinois Department of Veterans’ Affairs to release the
following record(s) identified, in the “Records Request” section, to the organization, agency, or
individual named hereon. AS COVERED BY 330 ILCS 70/0.01 et. seq.
*NAME:
(Type or Print)
SEND TO THE ABOVE ADDRESS ALONG WITH A COPY OF A VALID FORM OF IDENTIFICATION
(i.e., Driver’s License, State ID, or Medicaid Card)
IF YOU ARE NOT THE VETERAN LISTED ABOVE, YOU WILL NEED TO MARK YOUR APPLICABLE CLASSIFICATION
III.
AND PROVIDE THE DOCUMENTATION FOR THAT CLASSIFICATION LISTED BELOW.
Photo ID required for proof of requesting individual
I am:
Spouse/Surviving Spouse – Marriage Certificate/Proof of Power of Attorney/Veteran’s Death Certificate.
Dependent Child – Birth Certificate/Adoption Decree, showing relationship to the veteran. Relationship_______________________
Guardian – Court Declaration of Guardianship.
Fiduciary – Court Declaration of Fiduciary responsibility.
Executor – Documentation signed by decedent/Probate Order appointing Executor.
Accredited Service Organization – Proof of Power of Attorney.(VFW, DAV, etc.)
Authorized Government Agency .
Any other pertinent legal document(s) to verify the above status.
*
Phone
WRITTEN INFORMATION MUST BE LEGIBLE
*
*Individual/Organization (if applicable)
Fax
*
*Street
*City
*State
*Zip
Email
*Name
*Signature
I attest that the information provided is accurate, and that I am the legal next-of-kin or authorized recipient of the requested document(s).
AS COVERED BY 330 ILCS 70/0.01 et. seq.
I
L 497-0565
REVISED 11/2020