Dd Form 294 - Application For A Review By The Physical Disability Board Of Review Of The Rating Awarded Accompanying A Medical Separation From The Armed Forces Of The United States
Download a blank fillable Dd Form 294 - Application For A Review By The Physical Disability Board Of Review Of The Rating Awarded Accompanying A Medical Separation From The Armed Forces Of The United States in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dd Form 294 - Application For A Review By The Physical Disability Board Of Review Of The Rating Awarded Accompanying A Medical Separation From The Armed Forces Of The United States with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3APPLICATION FOR A REVIEW BY THE PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
OF THE RATING AWARDED ACCOMPANYING A MEDICAL SEPARATION
OMB No. 0704-0453
FROM THE ARMED FORCES OF THE UNITED STATES
(Please read Instructions on Page 3 BEFORE completing this application.)
The public reporting burden for this collection of information is estimated to average 45 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, Information Management Division,
1155 Defense Pentagon, Washington, DC 20301-1155 (0704-0453). 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.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE ADDRESS LISTED ON THE
BOTTOM OF PAGE 2.
PRIVACY ACT STATEMENT
AUTHORITY: 10. U.S.C. 1554(a); E.O. 9397.
PRINCIPAL PURPOSE(S): To apply for a review of the disability rating awarded to an individual separated but not retired for being medically unfit.
ROUTINE USE(S): The "Blanket Routine Uses" published at the beginning of the DoD's compilation of Systems of Records Notices apply to this
system.
DISCLOSURE: Voluntary; however, failure to provide identifying information may impede processing of this application. The request for Social
Security Number is strictly to assure proper identification of the individual and appropriate records.
1. APPLICANT DATA (The person whose discharge is to be reviewed.) (Print or type all information.)
a. BRANCH OF SERVICE
(X one)
ARMY
MARINE CORPS
NAVY
AIR FORCE
COAST GUARD
d. DATE OF SEPARATION
b. NAME
c. PAY GRADE
(YYYYMMDD)
e. SOCIAL SECURITY NO.
(Last, First, Middle Initial)
(Must be between 11 September 2001 and 31
(at time of separation)
December 2009 for review) (May be extended)
2. FINAL DISABILITY RATING AWARDED BY SERVICE FOR UNFITTING CONDITION(S)
(X one)
0%
10%
20%
3. ISSUES WHY THE RATING FOR THE CONDITION(S) WHICH RENDERED THE MEMBER UNFIT SHOULD BE CHANGED: (Continue in Item 12
if necessary)
4. IN SUPPORT OF THIS APPLICATION, THE FOLLOWING ATTACHED DOCUMENTS ARE SUBMITTED AS EVIDENCE: (Continue in Item 13
if necessary)
5. VETERANS AFFAIRS (VA) RATING INFORMATION (X all that apply)
a. I have received a VA disability rating that includes the condition(s) for which I was found unfit.
YES
NO
N/A
If Yes, I have also been rated for other conditions (list all other conditions in Item 14).
PENDING
b. I have attached my VA determination letter (answer N/A if answer to 5.a. is No or Pending).
YES
NO
N/A
If No, explain in item 14. See item 5 of instructions for pending determinations.
6. VA CONSENT (X one)
To review my service disability rating, I
do
do not consent to the release of my VA records. I understand that I need to complete,
sign and return the attached VA form 3288 (that has been partially completed as an aid for my use) with my application. I further understand the
PDRB will send my signed consent to VA for action and that the VA will provide the requested information to the PDRB directly.
7.a. COUNSEL/REPRESENTATIVE
NAME
AND ADDRESS
b. TELEPHONE NUMBER (Include Area Code)
(If any)
(Last, First, Middle Initial)
(See Item 7 of the instructions on Page 3 about counsel/representatives.)
c. E-MAIL
d. FAX NUMBER (Include Area Code)
8. APPLICANT MUST SIGN IN ITEM 11 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 a box below.
SPOUSE
WIDOW
WIDOWER
NEXT OF KIN
LEGAL REPRESENTATIVE
OTHER (Specify)
b. TELEPHONE NUMBER (Include Area Code)
9.a. CURRENT MAILING ADDRESS OF APPLICANT OR PERSON IN ITEM 8 ABOVE
(Forward notification of any change in address.)
c. CELL PHONE NUMBER (Include Area Code)
d. E-MAIL
CASE NUMBER
10. I have read the attached instruction for this item and understand that by requesting this review I give up my
right under 10 U.S.C. 1552 to petition my Service's Board for Correction of Military/Naval Records to review
(Do not write in this space)
and correct the rating for the medical condition(s) which made me unfit. I make the foregoing statements,
as part of my claim, with full knowledge of the 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.)
11.a. SIGNATURE (REQUIRED) (Applicant or person in Item 8 above)
b. DATE SIGNED
(YYYYMMDD)
DD FORM 294, JAN 2009
Page 1 of 3 Pages
PREVIOUS EDITION IS OBSOLETE.
Reset
Adobe Professional 8.0
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 9003 - Additional Questions To Be Completed By All Applicants For Permanent Residence In The United States
Financial
Form 9003 - Additional Questions To Be Completed By Applicants For Permanent Residence In The United States
Legal
Form 9003 - Additional Questions To Be Completed By All Applicants For Permanent Residence In The United States
Financial
Form 9003 - Additional Questions To Be Completed By All Applicants For Permanent Residence In The United States
Financial
U.s. Passport Renewal From Canada By Appointment Order Form, Form Ds11 - Application For A Us Passport From Canada
Life
Related Categories
Parent category: Business