Form Dd214 - Application For Copy Of Military Discharge Record In Person Or By Mail - 2015

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COUNTY OF SAN DIEGOdf

ERNEST J. DRONENBURG, JR.

ASSESSOR/RECORDER/COUNTY CLERK

APPLICATION FOR COPY OF MILITARY DISCHARGE RECORD IN PERSON or BY MAIL

California State Law, Government Code Section 6107 (b) permits only authorized persons as defined below to receive a certified copy of any

“discharge, certificate of service, certificate of satisfactory service, notice of separation, or report of separation of any member of the Armed Forces

of the United States.”

I would like a Certified Copy of the record identified on this application form. (In order to receive a Certified copy, you must indicate your

relationship to the person named on the document by selecting from the list below.)

I am:

The person who is the subject of the record.



A family member or legal representative of the person who is the subject of the record.



_______________________________

A member/employee of

, a county office that provides veteran’s benefits services.



_____________________

A United States official authorized to obtain this record on behalf of the following office/department



MILITARY DISCHARGE INFORMATION (PLEASE PRINT OR TYPE)

Name on Document-First Name

Middle Name

Last Name

Date of Discharge/Separation

STATEMENT OF IDENTITY FOR AUTHORIZED PERSON

I, _______________________________________________________________, swear under penalty of perjury that I am an authorized person, as I

(Print Name)

have indicated above, and am eligible to receive a certified copy of the military record identified on this form.

Sworn this _______ day of ________________________, 20 _______, at __________________________________, _________________

(Day)

(Month)

(Year)

(City)

(State)

________________________________________________________

Applicant’s Signature

(*)

Note: Your signature MUST be notarized if applying by mail. Notarization is NOT required if applying in person.

(*) Members of a law enforcement agency, state and local government agencies are being exempt from notarization. Federal agencies are required to have the sworn statement notarized,

unless the federal agency falls under the definition of a law enforcement agency.

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,

and not to the truthfulness, accuracy, or validity of that document.

Certificate of Acknowledgment

State of ______________________________________________________ County of ____________________________________________________________

On __________________________________________________before me, ________________________________________________________, Notary Public,

personally appeared _________________________________________________________________________________________________________________

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument, and acknowledged to me that

he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) or the entity upon

behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing

paragraph is true and correct.

Personally Known OR

Produced Identification.

WITNESS my hand and official seal.

Type of Identification produced _________________________

_____________________________________

Notary Signature

Mail to:

Name___________________________________________________________

Mail this request to:

Address_________________________________________________________

San Diego Recorder/County Clerk