Fonn I80 (Rev. 5/12)
(Page
crron
-Standud
Prescribed bv NARA (36 CFR | 228. I 6
Fynircc0t,irrr)ot(
OMBNo.3095-002S
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+ Requests from veterans
or
'o
I
ensure lhe besl
LITARY RTECORDS
dec€
ecs at http://www.archives.gov/veterans/military_service_recordif
NAME USED DURING SE:RVICE (last, firsr, and
SERVICE, PAST AND PRI]SENT
-
--
review lhe
serv tce,
instuclions betore
out this
form.
Please
N i\EEDED TO LOCATI' RT]COIIIDS
middle)
2. SOCIAL SECURIT}'NO.
3, DATI]OF BIRTH
prinl
4. PLACE OF BTRTH
(For an effective records search, it is tmDortart thal all service be shown below
)
SERVICE NUMBER
DATE ENTERED DATE RELEASED OPTICCR
ENLISTED
(If unknown. write "unknown"
BRANC}I OF SERVICE
I
I
ACTIVE
A.
COMPONENT
b. RESERVE
COMPONENT
NATIONAL
C.
GUARD
lf"YES"
IS THIS PERSON DECEAS|ED?
I *o !
.rrs
fNo
ON
I.
7 IS (W,,\S) TI-tlS PERSON
enter the date ofdeath
II
RETIRED FROM MILITARY SERVICE,i
!ves
_ TNF'ORNIATION AND/OR DOCLI}IONTS
CHECK THE ITEM(S) YOU ARE REQUESTING:
Form274 or equivalent. When was the DD Form(s) 214 issued? yEAR(S):
f IfOOmore
than one perio,C of service was performed, even in the same branch, there nray be more than one OOZtq
This form contains infitrmation normally needed to verif, military service. A copy may be sent to the veteran, the deceased veteran,s next ofkin. or
other persons or organizations if authorized in Section III, below. An UNDELETIID DD214 is ordinarily required to determine eligibility for
benefits. Sensitive items, such as, the character of separation, authority for separation, r'eason for separation, reenlistment eligibility code,
separation (SPD/SPN) code, and dates of time lost are usually shown.
An undeleted copy will be sent unless you specify a deleted copy. Indicate here if 1ou want a dleleted copy of the DD Form 214
The following items are deleted: authority for separation, reason for separation, recnlistment eligibility code, separation (SPD/SPN) code, and for
separations after June .\0,1979, character ofseparation and dates oftime lost.
.2.
I
!
!
All Documents in Official Military Personnel File (OMPF)
Medical Records(lncludesServiceTreatmentRecords.Health(outpatient)anddental
date for each admission must be provided:
Ott'..
records.) Ifhospitalized(inpatient),thefacilitvnameard
(Specify):
2. PURPOSE: (An explanation of
response and may result in a laster
the purpose of the request is strictly voluntary; howe",er, such information may help to provide the best possible
reply. lnformation provided will in no way be used to rnake a decision to deny the request.) Check appropriate box
! Benefits ! Employment n
! Other, explain:
V,q Loan
Medical ! Cenealogy f] Conection !
Programs I
A\D
personal
I|IGNATU]RS
t. REQUESTERIS:
(SignatureRequiredin#3belowofveteran,nextofkin,legalguardian,authoriz,zdgovernmentagentor"other"authorizedrepresentative
"other" authorized representative provide copy ofauthorization letter.) No signature requiredfor Archiyal records.
t---l
LJ
I
[]
n
Mrlitary service member or veteran identified in Section I, above
Next
ofkin ofdeceased veteran:
lf
Legal guardian (Must submit copy of court appoinnnent..l
Olher (s;peci$,)
(Relationship)
MUST HAVE PROOF OF DUATH - See item 2a on instruction sheet
2. SEND INFORMATION/DOCUMENTS TO:
(Please
prinl or type.
See item 4 on accomparrying instructions
)
Name
3. ALTTHORIiLATION SICNA'ILIRE WHEN REQTJIRED
fSee items 2a or 3a
on accomponying instructions ) [ declare (or certifu, veri$,, or state) under penaltl
of perjury under the laws of the United States of America that the inlormation in
thrs Section III ts true and correct No signature required for Archival records
Signature Required - Do not print
Date
l/
Street
City
Apt
State
Zip Code
Davtime phone
Fax Number
Email address
*This form is available alhltp://wwlo archives.gov/research/order/standard-form-l80.pdf onthe Naticnal Archives
and Records Administration (NARA) web site
+
Vallev Mills Police Deoartment
Authoritv to Release Information Waiver
Valley Mills Police Department
AUTHORITY TO RELEASE INFORMATION
TO WHOM IT'MAY CONCERN:
I hereby authorize the Valley
Mills Police Department and its authorized representatives bearing this
release, or a copy thereof, within one year of its date, to obtain any information in your files pertaining to
my employmetnt, military, credit, education or medical records, including not limited to academic,
achievement, attendance, athletic, personal history, and disciplinary records, medical records, and credit
records.
I hereby direct you to release such information upon request of the bearer. This release is executed with
full knowledge and understanding that the information is for official use. Consent is granted to all parties
to furnish such information, as described above, to third parties in the course of fulfilling its official
responsibilities. I hereby release you, as custodian of such records, and any school, college, university, or
other educations institution, hospital, or other repository of medical records, credit bureau, lending
institution, consumer reporting agency, or retail business establishment including its officers, employees,
or related personnel, both individually and collectively, from any and all liability for damages of whatever
kind, which mia! at any time result to me, my heirs, family or associates because of compliance with this
authorization and request to release information, or attempt to comply with it.
I am furnishing my Social Security Account Number on a voluntary basis with the understanding such is
not required by any law or regulation. I have been advised that all parties will utilize this number only to
facilitate the location of employment, military, credit, and educational records concerning me in
connection with this application. Should there be any question
ers
to the validity of this release, you may
contact me as indicated below:
Applicant's Printed Full Name:
Address:
Teleohone Number:
Applicant's Notarized Signature:
Sworn to and signed before me, on this
in and for
day of
county, in the state of
Signature of Notary Public:
NOTARY SEAL
Printed Name of Notary Public:
My Commission Expires
the