Sample Request For Status Information Letter Template
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4Request for Status Information Letter
VERIFY: I am not registered with the Selective Service System and requesting a Status Information Letter.
I am now 26 years old or older and was born after December 31, 1959.
NOTE:
No action will be taken on this request unless ALL REQUIRED information / documentation with an
*
asterisk (
) are received (where applicable). KEEP a copy of all documents and correspondence submitted.
__________________________________________________________________________
Section 1
:
*
Name ______________________________________________________________________________
*
*
*
First Name
Middle Name
Last Name
________________________________________________________
List any other names used
Include any multiple last names
*
Current Mailing Address _______________________________________________________________
*
Street Address
___________________________________________________________
*
*
*
City
State
Zip Code
*
Social Security Number ____________________________
*
Date of Birth _____________________________________
*
*
*
Month /
Day /
Year
Daytime Telephone Number _____________________________________________________________
E-mail Address ________________________________________________________________________
Section 2:
MILITARY:
List dates of active duty service:
________________________ to _________________________
List dates of reserve duty service:
________________________ to _________________________
List dates of military school service: ________________________ to _________________________
Military school attended: _____________________________________________________________
*
Attach copy of DD 214 (or DD Form 4 if still on active duty)
INCARCERATED
INSTITUTIONALIZED
HOSPITALIZED
HOME CONFINED :
*
List dates during which you were incarcerated, institutionalized, hospitalized, or confined to a home.
For multiple dates, list all:
___________
___________ , ___________
___________ , ___________
___________
to
to
to
*
Attach proof of each instance.
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