Form DD Form 2168 DD Form 2168 Application for Discharge of Member or Survivor of Membe

APPLICATION FOR DISCHARGE OF MEMBER OR SURVIVOR OF MEMBER
OF GROUP CERTIFIED TO HAVE PERFORMED ACTIVE DUTY
WITH THE ARMED FORCES OF THE UNITED STATES

OMB No. 0704-0100
OMB approval expires

(Read Instructions on back before completing form.)
The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0100). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. SEND COMPLETED FORM TO THE APPROPRIATE SERVICE ADDRESS
ON THE BACK OF THIS PAGE.

PRIVACY ACT STATEMENT
AUTHORITY: Public Law 95-202, Sec. 401, and EO 9397.
PRINCIPAL PURPOSE(S): To assist the Secretaries of the Armed Forces in determining if applicant was member of a group which has been found to have performed
active military service, and, after an affirmative finding as to the applicant, to assist the Secretary of an Armed Force in issuing an appropriate certificate of service.
ROUTINE USE(S): The information may be released to the civilian employer or contractual group or the Department of Homeland Security (for Coast Guard applicants)
to support the member's claim. To the Department of Veterans Affairs to provide substantiation for benefit eligibility. To the Department of Justice in pending or potential
litigation to which the record is pertinent.
DISCLOSURE: Voluntary; however, failure to provide identifying information may impede processing of this application. The use of Social Security Number is strictly to
assure proper identification of the individual and appropriate records.

I. GROUP MEMBER PERSONAL DATA
1.a. MEMBER'S NAME (Last, First, Middle and Maiden, if any)

D R A F T

4.a. PRESENT STREET ADDRESS (Incl. apartment number)

b. ALIAS(ES)

b. CITY

2. SSN

3. DATE OF BIRTH
(YYYYMMDD)

c. COUNTY

d. STATE

II. SERVICE GROUP DATA TO SUPPORT CLAIM
5. NAME OF GROUP SERVED WITH
6. IDENTIFICATION NO. 7. HIGHEST GRADE/RANK/RATING HELD

e. ZIP CODE

8. HIGHEST PAY GRADE
(or actual pay)

9. ENTRY INTO SERVICE
a. DATE (YYYYMMDD)

10. ACTUAL MILITARY SERVICE BEFORE/AFTER THIS SERVICE

b. PLACE (Include City and State of Military Installation)

a. DATES (YYYYMMDD)

b. DEPARTMENT(S)

12. GRADE/RANK/RATING
AT TIME OF ENTRY

11. HOME OF RECORD AT TIME OF ENTRY
a. STREET ADDRESS (Incl. apartment number)

b. CITY

c. COUNTY

13. MILITARY INSTALLATION WHERE ORDERED TO REPORT (Include City and State)

d. STATE e. ZIP CODE

14. SPECIALTY JOB TITLE(S)

15. DECORATIONS, MEDALS, BADGES, COMMENDATIONS, CAMPAIGN RIBBONS AWARDED/AUTHORIZED
16. TERMINATION OF GROUP SERVICE (Separation, Discharge, Resignation, etc.)
a. TYPE OF
TERMINATION

b. REASON

c. STATION BASE/LOCATION

d. SERVICE COMMAND
AFFILIATION

e. DATE SERVICE
TERMINATED (YYYYMMDD)

III. APPLICATION INFORMATION
Applicant must sign in the space provided. If the record in question is that of a person who is deceased or incompetent, legal proof of death or
incompetency must accompany this application. If the application is signed by the spouse, widow, widower, next of kin, or legal representative, give
relationship or status in the appropriate box below.
17. RELATIONSHIP TO
APPLICANT (X one)

a. SPOUSE

c. WIDOWER

e. LEGAL REPRESENTATIVE

b. WIDOW

d. NEXT OF KIN

f. OTHER (Specify)

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. (U.S. Code, Title 18, Sec. 287, 1001, provides a penalty of not more than $10,000 fine or
not more than five years imprisonment or both.)
18. APPLICANT
a. NAME (Last, First, Middle)

b. SSN

e. MAILING STREET ADDRESS (Incl. apartment number)

d. DATE SIGNED
(YYYYMMDD)

c. SIGNATURE

CITY

STATE

ZIP CODE

f. TELEPHONE (Include area code)

IV. DISCLOSURE OF INFORMATION
19. I hereby authorize the release of copies of any official records
maintained by the National Personnel Records Center to the
appropriate military personnel office (listed on the reverse side) for the
purpose of processing my application for discharge under
Public Law 95-202.

DD FORM 2168, 20080102 DRAFT

b. DATE SIGNED
(YYYYMMDD)

a. SIGNATURE

PREVIOUS EDITION IS OBSOLETE.

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INSTRUCTIONS

1. Use typewriter or print information when completing this form. Submit in original copy only. Complete all
items. If the question is not appropriate, write "NONE." Attach all documentation available to support
information you enter on the form.
2. The burden of proof is on the applicant to show he or she was part of the group that provided the
recognized services. List all attachments or enclosures. Use plain bond paper for additional explanation, if
needed.
3. Include any supporting documents which support your claim. Supporting material may include, but is not
limited to, separation discharge certificates, mission orders, identification cards, contracts or personnel action
forms, employment record, education certificates, diplomas, pay vouchers, certificates or awards, casualty
information, and any other supporting evidence of membership and character of service performed.
4. The appropriate service will not provide counsel representation for applicant, nor will it defray cost of such
counsel under any circumstances.
5. In the event the service decides information provided by the applicant is incomplete, the application will be
returned without prejudicing later information.

D R A F T

MAIL COMPLETED APPLICATION TO THE APPROPRIATE ADDRESS BELOW:
ARMY:

Commander
US Army Reserve Personnel Command (AHRC-PAV-V)
1 Reserve Way
St. Louis, MO 63132-5200

NAVY:

Navy Personnel Command
(PERS-312)
Millington, TN 38054-5045

MARINE CORPS:

Commandant of the Marine Corps (Code: MMSB-12)
2008 Elliot Road, Suite 222
Quantico, VA 22134-0001

AIR FORCE:

HQ AFPC/DPPRS
550 C Street West, Suite 3
Randolph AFB, TX 78150-4713

COAST GUARD:

United States Coast Guard
National Maritime Center
(NMC-4A)
4200 Wilson Blvd., Suite 630
Arlington, VA 22203-1804

DD FORM 2168 (BACK), 20080102 DRAFT