COUNTY OF SAN DIEGOdf
ERNEST J. DRONENBURG, JR.
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.)
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
Date of Discharge/Separation
STATEMENT OF IDENTITY FOR AUTHORIZED PERSON
I, _______________________________________________________________, swear under penalty of perjury that I am an authorized person, as I
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 __________________________________, _________________
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
WITNESS my hand and official seal.
Type of Identification produced _________________________
Mail this request to:
San Diego Recorder/County Clerk
ATTN: Vital Record
City, State, Zip____________________________________________________
P.O. Box 121750
San Diego, CA 92112-1750