3
NOVEMBER 1, 2000
Standard Form 180 (Rev. 4-96)
Prcwrihed by NARA (36CFR I22.l62fa
NSN 7540-00-147.-9360
OMB No. 3095- 0029 rpirc MONK
REQUEST PERTAINING
TO MILITARY RECORDS
To ensure the best possible service, please thoroughly review the instructions ut the bottom before
filling out this form. Please print clearly or type. If you need more space, use plain paper.
SECTION I INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much as possible.)
I. NAME USED DURING SERVICE (Last, first, and middle)
2. SOCIAL SECURITY NO.
3. DATE OF BIRTH
4. PLACE OF BIRTH
5. SERVICE, PAST AND PRESENT
(For an effective records search, it is important that ALL service be shown below.)
DATES OF SERVICE CHECK ONE SERVICE NUMBER
. . DURING THIS PERIOD
BRANCH OF SERVICE DATE ENTERED DATE RELEASED OFFICER ENLISTED (If unknown, please write unknown.')
a. ACTIVE
SERVICE
b. RESERVE
SERVICE
c. NATIONAL
CUARD
6. IS THIS PERSON DECEASED? If "YES enter the dale of death. I 7. IS (WAS) THIS PERSON RETIRED FROM MILITARY SERVICE?
no Dyes yes no
SECTION II - INFORMATION ANDOR DOCUMENTS REQUESTED
I. REPORT OF SEPARATION (DD Form 214 or equivalent) This contains information normally needed to verify military service. It may be furnished to the veteran,
the deceased veteran's next of kin, or other persons or organizations if authorized in Section III, below. NOTE: If more than one period of service was performed, even in
the same branch, there may be more than one Report of Separation. Be sure to show EACH year for which you need a copy.
An UNDELETED Report of Separation is requested for the years
This normally will be a
copy of the full separation document including such sensitive items as the character of separation, authority for separation, reason for separation, reenlisimeni eligibility
code, separation (SPDSPN) code, and dates of lime lost. An undeleted version is ordinarily required to determine eligibility for benefits.
Q A DELETED Report of Separation is requested for die years . The following
information will be deleted from the copy sent: authority for separation, reason for separation, reenlistment eligibility code, separation (SPDSPN) code, and for
separations after June 30, 1979, character of separation and dates of time lost.
-' - - 1 i . i . i . . ...... , . , i i
OTHER INFORMATION ANDOR DOCUMENTS REQUESTED -
3. PURPOSE (OPTIONAL-An explanation of the purpose of the request is strictly voluntary. Such information may help the agency answering this request to provide
the best possible response and will in no way be used to make a decision to deny the request.)
SECTION III RETURN ADDRESS AND SIGNATURE
I. REQUESTER IS
f1 Military service member or veteran identified in Section I, above
C3 Next of kin of deceased veteran '
(relation)
2. SEND INFORMATIONDOCUMENTS TO:
(Please print or type. See Instruction 3, below.)
Name
0 Legal guardian (must submit copy of court appointment)
O Other (specify)
3. AUTHORIZATION SIGNATURE REQUIRED (See instruction 2, below.)
I declare (or certify, verify, or state) under penalty of perjury under the laws of the
United States of America that the information in this Section III is true and correct.
Street
Apt.
City
State
ZIP Code
INSTRUCTIONS
Signature of requester (Please do not print.)
Date of this request
J.
Daytime phone
Please detach this portion before submitting request.
I. Information needed to locate records. Certain identifying information is necessary to determine the location of an individual's record of military service. Please try
answer each item on this form. If you do not have and cannot obtain the information for an item, show "NA," meaning the information is "not available." Include as mu
of the requested information as you can.
to
much
2. Restrictions on release of information. Release of information is subject to restrictions imposed by the military services consistent with Department of Defense
regulations and the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The service member (either past or present) or the member's legal
guardian has access to almost any information contained in that member's own record. Others requesting information from military personnelhealth records must have the
release authorization in Section III of this form signed by the member or legal guardian, but if the appropriate signature cannot be obtained, only limited types of information
can be provided. If the former member is deceased, surviving next of kin may, under certain circumstances, be entitled to greater access to a deceased veteran's records
than a member of die public. The next of kin may be any of the following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. Employers and
others needing proof of miliury service are expected to accept the information shown on documents issued by the military service departments at the time a service member
is separated.
3. Where reply may be sent. The reply may be sent to the member or any oilier address designated by the member or other authorized requester.
4. Charges for service. There is no charge for most services provided to members or their surviving next of kin. A nominal fee is charged for certain types of service. In
most instances service fees cannot be determined in advance. If your request involves a service fee, you will be notified as soon as that determination is made.
SEE REVERSE FOR PRIVACY ACT AND PUBLIC BURDEN STATEMENTS