Ca Arng Form 149 - Application For Correction Of Military Records Under The Provisions Of California Military And Veterans Code 474
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1
2APPLICATION FOR CORRECTION OF MILITARY RECORDS UNDER THE
CASE NUMBER
PROVISIONS OF CALIFORNIA MILITARY AND VETERANS CODE 474
Do not write in this space
(Please read instructions on reverse side BEFORE completing this application.)
RETURN COMPLETED FORM TO THE ADDRESS ON THE BACK OF THIS PAGE.
PRIVACY ACT STATEMENT
CA MVC 474
AUTHORITY:
NONE.
ROUTINE USE(S):
PRINCIPAL PURPOSE:
To apply to the CA NG Board of Corrections to Military
Records. This form and attached supporting
documentation (if any) is used by the board members to
Voluntary; however, failure to provide identifying information may
DISCLOSURE:
assess your application and when an error or injustice is
impede processing of this application. The request for Social
substantiated by the applicant, make recommendation of
Security Number is strictly to assure proper identification of the
relief to The Adjutant General.
individual and appropriate records.
1. APPLICANT DATA
(The person whose record is being corrected.)
a. NAME:
(Print - Last, First, Middle Initial)
b. RANK/GRADE
c. SSN
d. DOD ID #
(If applicable)
3.TYPE OF DISCHARGE
4. DATE OF DISCHARGE OR RELEASE
2. PRESENT STATUS WITH RESPECT TO THE ARMED
(If by court-martial,
state the type of court)
FROM CALIFORNIA NATIONAL GUARD
SERVICES
(Active Duty, Reserve, National Guard, Retired, Discharged,
Deceased)
(YYYYMMDD)
(Entry required) (Continue in remarks if additional space is required)
5. I REQUEST THE FOLLOWING ERROR OR INJUSTICE IN THE RECORD BE CORRECTED:
6. I BELIEVE THE RECORD TO BE IN ERROR OR UNJUST FOR THE FOLLOWING REASON:
(Entry required)
(Continue in remarks if additional space is required)
7. ORGANIZATION AND APPROXIMATE DATE
AT THE TIME THE ALLEGED ERROR OR INJUSTICE IN THE RECORD OCCURRED
(YYYYMMDD)
(Entry required)
b. IF MORE THAN THREE YEARS SINCE THE ALLEGED ERROR OR INJUSTICE WAS DISCOVERED, STATE WHY
8. DISCOVERY OF ALLEGED ERROR OR INJUSTICE
THE BOARD SHOULD FIND IT IN THE INTEREST OF JUSTICE TO CONSIDER YOUR APPLICATION.
a. DATE OF DISCOVERY:
9. IN SUPPORT OF APPLICATION, I SUBMIT AS EVIDENCE THE FOLLOWING ATTACHED DOCUMENTS:
(If military documents or medical records are pertinent to your case, list each document and include a copy with your application)
(X one below)
10. In the event your application is boarded you have the right to appear before the board in Sacramento, CA (at no expense to the government)
I desire to appear before the board in Sacramento, CA
No, I do not wish to appear before the board. Consider my application based on records and evidence.
11a. COUNSEL
(include area code)
NAME
and ADDRESS
b. TELEPHONE
(if any)
(Last, First, Middle Initial)
(include Zip Code)
c. E-MAIL ADDRESS
(include area code)
d. FAX NUMBER
12. APPLICANT MUST SIGN IN BLOCK 15 BELOW. If the record in question is that of a deceased or incompetent person, LEGAL PROOF OF
DEATH OR INCOMPETENCY MUST ACCOMPANY THE APPLICATION. If the application is signed by other than the applicant, indicate
the name
(print)
and relationship by marking one box below.
SPOUSE
WIDOW
WIDOWER
NEXT OF KIN
LEGAL REPRESENTATIVE
OTHER
(Specify)
(include area code)
b. TELEPHONE
13a. COMPLETE CURRENT ADDRESS
(include Zip Code)
OF APPLICANT OR PERSON
c. E-MAIL ADDRESS
IN BLOCK 12 ABOVE
(Forward notification of all changes of address.)
(include area code)
d. FAX NUMBER
14. I MAKE THE FOREGOING STATEMENTS, AS PART OF MY CLAIM, WITH FULL KNOWLEDGE, OF THE PENALTIES INVOLVED FOR
WILLFULLY MAKING A FALSE STATEMENT OR CLAIM.
CA MVC 474
15. SIGNATURE
(Applicant must sign here)
16. DATE SIGNED
(YYYYMMDD)
CA ARNG FORM 149 1 JAN 2013
All Previous Editions are Obsolete
Page 1 of 2
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