Application For Dd214 (Military Discharge) Page 2

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SPECIAL NOTICE TO VETERANS
You may be eligible for a free certified copy if you are applying for a veteran’s pension or certain
other Veteran’s Administration benefits.
(Section 6107, Government Code State of California)
THIS DOES NOT APPLY TO SOCIAL SECURITY AND OTHER CIVILIAN BENEFITS, EVEN IF
YOU ARE A VETERAN.
If you believe you qualify for a free certified copy under these provisions, complete the following
affidavit.
I hereby apply for a free certified copy of the record as shown on the reverse side and declare
under penalty of perjury that the free copy is to be furnished to
_______________________________________ in a claim for _________________________________
FEDERAL OR STATE AGENCY
TYPE OF BENEFIT
___________________
________________________________________
_____________________
DATE
SIGNATURE OF VETERAN OR AUTHORIZED AGENT
RELATIONSHIP OF AGENT
NUMBER-STREET
CITY
STATE
ZIP
Note: The free copy issued on this affidavit will bear the following wording:
This certified copy has been issued free of charge on the declaration under penalty of perjury that it is to be
used in a claim to the Federal Government or the State of California for veteran’s benefits.

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