This form contains 72 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
DD Form 214 Request
DD Form 214 or Equivalent Checkbox
Check this box to request a DD Form 214 or an equivalent document.
DD Form 214 Issuance Year(s) Text
Provide the year(s) in which the DD Form 214 or equivalent was issued to the veteran, or the date of separation.
DD Form 214 Deleted Copy Checkbox
Check this box if you want a DELETED copy of the DD Form 214, which will have certain items blacked out as described in the form.
Deceased Status
Deceased Status - No Checkbox
Check this box if the person whose records are being requested is not deceased.
Deceased Status - Yes Checkbox
Check this box if the person whose records are being requested is deceased; you must also provide the date of death.
Date of Death Date
Provide the date of death if the veteran is deceased.
Dental Records Request
Dental Records Checkbox
Check this box if only dental records are needed from the medical record.
First Active Service Record
First Active Service Branch Combobox
Enter the branch of service for the first active service record.
Unknown Auxiliary Philippine Commonwealth Army Public Health Service Army Philippine Guerrillas Philippine Scouts Army Air Corps Army Air Force Air Force Marine Corps Coast Guard Navy
First Active Service Date Entered Date
Provide the date the service member entered their first active service record.
First Active Service Date Released Date
Provide the date the service member was released from their first active service record.
First Active Service Officer Checkbox
Check this box if the first active service record was as an officer.
First Active Service Enlisted Checkbox
Check this box if the first active service record was as an enlisted person.
First Active Service Number Text
Enter the service number for the first active service record.
First Active Service DOD ID / EDIPI Number Text
Enter the Department of Defense ID (DOD ID) or Electronic Data Interchange Personal Identifier (EDIPI) number for the first active service record.
General
Sign here if you declare that the information in this Section 3 is true and correct and that I authorize the release of the requested information. (Signature required for non-archival records.) Signature
Last Duty Station
Last Duty Station Text
Provide the last duty station(s).
Medical Records Request
Medical Records Checkbox
Check this box to request general medical records, which include health (outpatient), extended ambulatory, and dental records.
Inpatient/Hospitalization Facility Name Text
Enter the name of the facility from which inpatient or hospitalization records are being requested.
Last Treated Year Number
Enter the year the patient was last treated at the specified facility.
Inpatient/Hospitalization Records Checkbox
Check this box if you are specifically requesting inpatient or hospitalization medical records.
Military Retirement Status
Military Retirement Status No Checkbox
Check this box if the person did not retire from military service.
Military Retirement Status Yes Checkbox
Check this box if the person retired from military service.
Official Military Personnel File Request
Official Military Personnel File (OMPF) Request Checkbox
Check this box to request the Official Military Personnel File, which includes duty stations, assignments, training, qualifications, awards, decorations, disciplinary actions, administrative remarks, and enlistment/discharge information.
Other Document Request
Other (Please Specify) Checkbox
Check this box if you are requesting a document not listed above and will provide specific details.
Other Document Request Details Text
Provide a detailed description of the other document or information being requested.
Purpose of Request
Purpose Explanation Text
Provide a detailed explanation for the purpose of this request.
1 Benefits Checkbox
Check this box if the purpose of the request is for benefits.
2 Employment Checkbox
Check this box if the purpose of the request is for employment.
3 VA Loan Programs Checkbox
Check this box if the purpose of the request is for VA Loan Programs.
4 Medical Checkbox
Check this box if the purpose of the request is for medical reasons.
5 Genealogy Checkbox
Check this box if the purpose of the request is for genealogy research.
6 Correction Checkbox
Check this box if the purpose of the request is for correction of records.
7 Personal Checkbox
Check this box if the purpose of the request is for personal use.
8 Other Checkbox
Check this box if the purpose of the request falls under none of the listed categories and requires an explanation.
Recipient Address and Contact
Recipient Name Text
Enter the full name of the recipient.
Recipient Street Address Text
Enter the street address of the recipient.
Recipient Apartment Number Text
Enter the apartment number of the recipient, if applicable.
Recipient City Text
Enter the city of the recipient.
Recipient State Text
Enter the state of the recipient.
Recipient ZIP Code Text
Enter the ZIP code of the recipient.
Recipient Daytime Phone Text
Enter the daytime phone number of the recipient.
Recipient Fax Number Text
Enter the fax number of the recipient.
Recipient Email Address Text
Enter the email address of the recipient.
Requester Information
Requester Name Text
Enter the full name of the person making this request.
Relationship to Veteran Text
Enter your relationship to the veteran.
Requester Status
Deceased Veteran's Next-of-Kin Checkbox
Check this box if you are the deceased veteran's next-of-kin, and remember to submit proof of death as instructed.
Military Service Member or Veteran Checkbox
Check this box if you are the military service member or veteran identified in Section 1 of the form.
Veteran's Legal Guardian or Authorized Representative Checkbox
Check this box if you are the veteran's legal guardian (and must submit a copy of Court Appointment) or authorized representative (and must submit a copy of an Authorization Letter or Power of Attorney).
Other Requester Status Checkbox
Check this box if your requester status is not covered by the other options and specify your status in the provided field.
Requester Other Relationship Text
Specify the relationship of the requester to the veteran if it is not covered by the predefined options.
Second Reserve Service Record
Second Reserve Branch of Service Combobox
Enter the branch of service for the second reserve record.
Unknown Auxiliary Philippine Commonwealth Army Public Health Service Army Philippine Guerrillas Philippine Scouts Army Air Corps Army Air Force Air Force Marine Corps Coast Guard Navy
Second Reserve Date Entered Date
Provide the date the second reserve service began.
Second Reserve Date Released Date
Provide the date the second reserve service was released.
Second Reserve Officer Service Checkbox
Check this box if the second service record for Reserve was as an Officer.
Second Reserve Enlisted Service Checkbox
Check this box if the second service record for Reserve was as Enlisted personnel.
Second Reserve Service Number Text
Enter the service number for the second reserve service record. If unknown, write 'unknown'.
Second Reserve DOD ID / EDIPI Number Text
Enter the Department of Defense ID or Electronic Data Interchange Personal Identifier number for the second reserve service record.
Signature Date
Signature Date Date
Enter the date the form is signed.
Third National Guard Service Record
Third National Guard Branch of Service Combobox
Please enter the branch of service for the third National Guard record.
Unknown Air National Guard Army National Guard
Third National Guard Date Entered Date
Please enter the date the service member entered service for the third National Guard record.
Third National Guard Date Released Date
Please enter the date the service member was released from service for the third National Guard record.
Third National Guard Officer Checkbox
Check this box if the service member was an officer during their third National Guard service record.
Third National Guard Enlisted Checkbox
Check this box if the service member was enlisted personnel during their third National Guard service record.
Third National Guard Service Number Text
Please enter the service number for the third National Guard record. If unknown, write 'unknown'.
Third National Guard DOD ID / EDIPI Number Text
Please enter the DOD ID or EDIPI number for the third National Guard record.
VA Claim Information
VA Claim Information No Checkbox
Check this box if the person has NOT filed a claim with the VA.
VA Claim Information Yes Checkbox
Check this box if the person HAS filed a claim with the VA, and provide the VA Claim/File # if known.
VA Claim or File Number Text
Please provide the VA claim or file number for this person if known.
Veteran Identification
1. Name Used During Service Text
Enter the full name (last, first, full middle) used by the veteran during their service.
2. Social Security Number Text
Provide the veteran's Social Security Number.
3. Date of Birth Date
Enter the veteran's date of birth.
4. Place of Birth Text
Enter the city, state, and country where the veteran was born.