Dd Form 149 - Application For Correction Of Military Record
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1
2APPLICATION FOR CORRECTION OF MILITARY RECORD
OMB No. 0704-0003
UNDER THE PROVISIONS OF TITLE 10, U.S. CODE, SECTION 1552
OMB approval expires
(Please read Privacy Act Statement and instructions on back BEFORE completing this application.)
Dec 31, 2017
The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (0704-0003). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection
of information if it does not display a currently valid OMB control number.
RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS ON THE BACK OF THIS PAGE.
1. APPLICANT DATA
(The person whose record you are requesting to be corrected.)
a. BRANCH OF SERVICE (X one)
ARMY
NAVY
AIR FORCE
MARINE CORPS
COAST GUARD
c. PRESENT OR LAST
d. SERVICE NUMBER (If applicable)
e. SSN
b. NAME (Print - Last, First, Middle Initial)
PAY GRADE
2. PRESENT STATUS WITH RESPECT TO THE
3. TYPE OF DISCHARGE
4. DATE OF DISCHARGE OR RELEASE
(If by court-martial, state
ARMED SERVICES
(Active Duty, Reserve,
the type of court.)
FROM ACTIVE DUTY
(YYYYMMDD)
National Guard, Retired, Discharged, Deceased)
5. I REQUEST THE FOLLOWING ERROR OR INJUSTICE IN THE RECORD BE CORRECTED AS FOLLOWS:
(Entry required)
6. I BELIEVE THE RECORD TO BE IN ERROR OR UNJUST FOR THE FOLLOWING REASONS:
(Entry required)
YES
b. IF YES, WHAT WAS THE DOCKET NUMBER?
c. DATE OF THE DECISION
a. IS THIS A REQUEST FOR RECONSIDERATION
OF A PRIOR APPEAL?
NO
7. ORGANIZATION AND APPROXIMATE DATE
AT THE TIME THE ALLEGED ERROR OR INJUSTICE IN THE RECORD
(YYYYMMDD)
OCCURRED
(Entry required)
8. DISCOVERY OF ALLEGED ERROR OR INJUSTICE
a. DATE OF DISCOVERY
b. IF MORE THAN THREE YEARS SINCE THE ALLEGED ERROR OR INJUSTICE WAS DISCOVERED, STATE WHY THE
(YYYYMMDD)
BOARD SHOULD FIND IT IN THE INTEREST OF JUSTICE TO CONSIDER THE APPLICATION.
9. IN SUPPORT OF THIS APPLICATION, I SUBMIT AS EVIDENCE THE FOLLOWING ATTACHED DOCUMENTS:
(If military documents or medical
records are pertinent to your case, please send copies. If Veterans Affairs records are pertinent, give regional office location and claim number.)
10. I DESIRE TO APPEAR BEFORE THE BOARD IN WASHINGTON,
YES. THE BOARD WILL
NO. CONSIDER MY APPLICATION
D.C.
DETERMINE IF WARRANTED.
BASED ON RECORDS AND EVIDENCE.
(At no expense to the Government) (X one)
11.a. COUNSEL
NAME
and ADDRESS
(If any)
(Last, First, Middle Initial)
(Include ZIP Code)
b. TELEPHONE (Include Area Code)
c. E-MAIL ADDRESS
d. FAX NUMBER (Include Area Code)
e. I WOULD LIKE ALL CORRESPONDENCE/DOCUMENTS SENT TO ME ELECTRONICALLY.
YES
NO
12. APPLICANT MUST SIGN IN ITEM 15 BELOW. If the record in question is that of a deceased or incompetent person, LEGAL PROOF OF
DEATH OR INCOMPETENCY MUST ACCOMPANY THE APPLICATION. If the application is signed by other than the applicant, indicate
the name
(print)
and relationship by marking one box below.
SPOUSE
WIDOW
WIDOWER
NEXT OF KIN
LEGAL REPRESENTATIVE
OTHER (Specify)
13.a. COMPLETE CURRENT ADDRESS
OF APPLICANT OR PERSON
(Include ZIP Code)
b. TELEPHONE (Include Area Code)
IN ITEM 12 ABOVE
(Forward notification of all changes of address.)
c. E-MAIL ADDRESS
d. FAX NUMBER (Include Area Code)
CASE NUMBER
14. I MAKE THE FOREGOING STATEMENTS, AS PART OF MY CLAIM, WITH FULL KNOWLEDGE OF THE
(Do not write in this space.)
PENALTIES INVOLVED FOR WILLFULLY MAKING A FALSE STATEMENT OR CLAIM.
(U.S. Code, Title 18,
Sections 287 and 1001, provide that an individual shall be fined under this title or imprisoned not more than 5 years, or both.)
15. SIGNATURE
(Applicant must sign here.)
16. DATE SIGNED
(YYYYMMDD)
DD FORM 149, DEC 2014
PREVIOUS EDITION IS OBSOLETE.
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