Na Form 13075 - Questionnaire About Military Service Page 2
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2OMB No. 3095-0039 Expires 7/31/2017
QUESTIONNAIRE ABOUT MILITARY SERVICE
Please complete this form to the best of your ability.
Name(s) used during service (and nicknames, if any):
Branch of Service:
Last
First
Middle
Army
Air Force
Navy
Marine Corps
Coast Guard
Veteran’s Social Security Number:
Date of Birth:
City and State (Country) of Birth:
Served as:
Serial/Service number(s):
Home Address:
Officer
When entered service:
Street
Enlisted
If enlisted:
volunteered
drafted
City
County
State
Was service six months active duty for
training only?
Yes
No
When released from active duty:
City
County
State
Final Rank:
Selective Service:
Local Board Number
City
State
Veteran’s Selective Service Number
Names of close relatives when military service began
(parents, siblings, spouse, children):
Place of Enlistment or Induction
Month/Day/Year began active duty:
(where veteran took oath of service, such as examining station, reception center, or
place of basic training.) Show name of military facility, city, state:
Place of basic training and month/day/year began
(if different from place and date shown on line above):
Type of military assignment
(infantry, airborne, engineer, bombers, fighters, supply, maintenance, food service, etc.):
Last military organization and location
(show full unit designations, such as army, division, regiment, battalion, company):
Separation Station
Date Released from Active Duty
(if this service member was released at a separation station after leaving the last “permanent”
organization or “unit”, include location of separation station):
(Month/Day/Year):
Month/Day/Year of any reenlistment(s) (i
Date of Death (if veteran is deceased):
nclude full designation and location of unit to which assigned at that time):
Did the veteran ever:
a.
File a claim for VA benefits?
No
Yes
Don’t Know
If yes, show VA Claim Number:
If yes, show branch of service
b.
Serve in the Reserves after release
No
Yes
Don’t Know
from active duty period shown above?
show mo/yr from
to
c.
Receive a state bonus for military
If yes, show state
mo/yr paid
No
Yes
Don’t Know
service?
If yes, show state
Army
Air
d.
Serve in the National Guard?
No
Yes
Don’t Know
show mo/day/yr from
to
If yes, show branch of service
e.
Retire from any military service
No
Yes
Don’t Know
branch?
show mo/yr retired
If yes, show branch of service
f.
Spend time on the Temporary
No
Yes
Don’t Know
Disability Retired List (TDRL)?
show mo/day/yr from
to
If yes, show branch of service
g.
Serve active duty in any other military
No
Yes
Don’t Know
service branch in later years?
show mo/day/yr from
to
If yes, show agency name
h.
Work for the Federal Government as a
No
Yes
Don’t Know
civilian?
show city/state
show mo/day/yr from
to
Purpose: (Optional – An explanation of the purpose of this request is strictly voluntary.)
Relationship to veteran in question:
SIGNATURE:
TODAY’S
DAYTIME
DATE:
PHONE NUMBER: (
)
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION
NA FORM 13075 (Page 2 of 2) (REV. 06/11)
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