Fillable Form 20221031: (Please read Privacy Act Statement and (Washington Headquarters Services)

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Form 20221031: (Please read Privacy Act Statement and (Washington Headquarters Services)

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DD FORM 149, DEC 2019
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3
Prescribed by: DoDD 1332.41, DoDI 1332.28
APPLICATION FOR CORRECTION OF MILITARY RECORD
UNDER THE PROVISIONS OF TITLE 10, U.S. CODE, SECTION 1552
(Please read Privacy Act Statement and instructions on back BEFORE completing this application.)
OMB No. 0704-0003
OMB approval expires:
20221031
DO NOT WRITE BELOW
CASE NUMBER
SECTION 1: SERVICE MEMBER (The person whose discharge is to be reviewed.)
PLEASE PRINT OR TYPE INFORMATION
1. BRANCH AT TIME OF ERROR OR INJUSTICE ARMY NAVY AIR FORCE COAST GUARD MARINE CORPS
2. COMPONENT AT TIME OF ERROR OR INJUSTICE REGULAR RESERVE GUARD
3. NAME WHILE
SERVING
4. CURRENT NAME
(if different)
Last
First
MI Suffix
Last
First
MI Suffix
5a. SSN WHILE SERVING - -
CURRENT SSN (if different)
- -
5b. (provide, if applicable)
DoD ID Number, SERVICE NUMBER, or TIN
6. MAILING ADDRESS (If Service Member is deceased, skip this question.)
Street
City, State / APO / Country or Foreign Address ZIP
Email Phone
SECTION 2: SEPARATION INFORMATION (if not currently serving)
7. CURRENTLY SERVING? YES NO
8. DATE OF SEPARATION (YYYYMMDD)
9. CHARACTER OF SERVICE (If by court-martial, also state Type of Court in space provided.)
Honorable
Under Honorable Conditions (General)
Under Other than Honorable Conditions
Dismissal
Uncharacterized / Entry Level Separation
Other
Bad Conduct Discharge Dishonorable
Type of Court
SECTION 3: ERROR OR INJUSTICE
10a. IS THIS A REQUEST FOR RECONSIDERATION OF A PRIOR APPLICATION TO THE BOARD?
YES NO
10b. IF YES AND KNOWN, PROVIDE CASE NUMBER
AND DECISION DATE (YYYYMMDD)
11. CATEGORY (Select all that apply. Example: Administrative Correction - change in name, DOB, SSN.)
Administrative Correction
Disability
Pay & Allowance
Promotions / Rank
Decoration / Awards
Discharge / Separation
Performance / Evaluations / Derogatory Information
Other
12. WHAT CORRECTION AND RELIEF ARE YOU REQUESTING FOR THIS ERROR OR INJUSTICE IN THE SERVICE MEMBER'S RECORD? (required)
13. ARE ANY OF THE FOLLOWING ISSUES/CONDITIONS RELATED TO YOUR REQUEST: (Select all that apply.)
PTSD TBI Other Mental Health Sexual Assault / Harassment DADT Transgender Reprisal / Whistleblower
14. WHY SHOULD THIS CORRECTION BE MADE? (required)
15. APPROXIMATE DATES (YYYYMMDD)
THE ERROR OR INJUSTICE OCCURRED: AND WAS DISCOVERED:
IF THE DATE OF DISCOVERY IS MORE THAN 3 YEARS AGO, EXPLAIN YOUR DELAY AND WHY THE BOARD SHOULD CONSIDER YOUR
REQUEST. REFER TO BLOCK 18.
DD FORM 149, DEC 2019
PREVIOUS EDITION IS OBSOLETE.
Page 2 of 3
Prescribed by: DoDD 1332.41, DoDI 1332.28
17. DO YOU WISH TO APPEAR AT YOUR
OWN EXPENSE BEFORE THE BOARD IN
WASHINGTON, D.C.?
YES. (IN PERSON)
YES. (VIA VIDEO /
TELEPHONE)
NO. CONSIDER MY APPLICATION
BASED ON RECORDS & EVIDENCE.
THE BOARD WILL DETERMINE IF WARRANTED.
18. ADDITIONAL REMARKS/CONTINUATION OF INFORMATION (If more space is needed, please submit additional narrative as required.)
SECTION 4: EVIDENCE, RECORDS, AND ADDITIONAL REMARKS
19. IN SUPPORT OF THIS CLAIM, THE FOLLOWING DOCUMENTARY EVIDENCE IS ATTACHED (LIST DOCUMENTS): Example evidence / records:
Separation packet, medical documents (e.g. diagnosis, VA rating), post-service documents (e.g. diplomas, professional certificates, character references),
and/or investigations. (Do NOT submit irreplaceable original documents. They will NOT be returned.)
a. d. g.
b. e. h.
c f. i.
LIST ADDITIONAL SUPPORTING DOCUMENTS (if needed)
IMPORTANT NOTE: If the basis of your request involves the effects of one or more physical, medical, mental, and/or behavioral health condition(s) and if
available, please attach copies of any VA rating decisions, relevant medical records, and counseling treatment records.
SECTION 5: CLAIMANT (if other than the Service Member)
20. RELATION TO SERVICE MEMBER
Claimants are normally Service Members seeking to correct their own records. The Service Member or former Service Member is not able to sign the
application because they are
deceased, incapacitated, or other
Please designate appropriate signatory below:
I am the heir of the Service Member:
widow(er), son, daughter, parent, sibling, Other
Please provide Service Member's death certificate and marriage license or heir's birth certificate, as appropriate to prove relationship.
I am the
conservator, guardian, or attorney-in-fact of the Service Member.
Please provide a notarized power of attorney or court appointment of conservatorship or guardianship to prove status.
I am the spouse, former spouse, or dependent of the Service Member.
Please provide marriage license, divorce decree, or dependent birth certificate, as appropriate to prove relationship
21. NAME
Last
First
MI Suffix
22. MAILING ADDRESS Street
City, State / APO / Country or Foreign Address ZIP
Email Phone
SECTION 6: REPRESENTATIVE OR COUNSEL (if applicable)
The following representative is authorized to receive and provide communication regarding this application.
23. NAME
Last
First
MI Suffix
24. ORGANIZATION
25. MAILING ADDRESS Street
City, State / APO / Country or Foreign Address ZIP
Email Phone
SECTION 7: SIGNATURE
26. I WOULD LIKE TO RECEIVE ALL CORRESPONDENCE & DOCUMENTS ELECTRONICALLY.
(This may reduce overall processing time.)
YES NO
CERTIFICATION: I MAKE THE FOREGOING STATEMENTS, AS PART OF THIS CLAIM, WITH FULL KNOWLEDGE OF THE PENALTIES INVOLVED
FOR WILLFULLY MAKING A FALSE STATEMENT OR CLAIM. (U.S. Code, Title 18, Section 287 and 1001, provide that an
individual shall be fined under this title or imprisoned not more than 5 years, or both.)
27a. SIGNATURE
27b. DATE SIGNED (YYYYMMDD)
16. IS THIS REQUEST RELATED TO ANY
OF THESE WARS OR CONTINGENCY
OPERATIONS?
Yes (Select all that apply.
No
Operation Freedom Sentinel (OFS) (01/01/2015 - Present) Persian Gulf War (08/02/1990 - 11/30/1995)
Operation Inherent Resolve (OIR) (08/08/2014 - Present) Vietnam War (01/01/1961 - 04/30/1975)
Operation Enduring Freedom (OEF) (09/11/2001 -
12/31/2014)
Korean War (06/27/1950 - 07/27/1954)
Operation New Dawn (OND) (09/01/2010 - 12/15/2011)
World War II (12/07/1941 - 09/02/1945)
Operation Iraqi Freedom (OIF) (03/19/2003 - 08/31/2010)
Other
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signature
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DD FORM 149, DEC 2019
PREVIOUS EDITION IS OBSOLETE.
Page 3 of 3
Prescribed by: DoDD 1332.41, DoDI 1332.28
INSTRUCTIONS FOR COMPLETION OF DD FORM 149
Under Title 10 United States Code Section 1552, current and former members of the Armed Forces, their lawful or legal representatives, spouses and ex-
spouses of former members seeking Survivor Benefit Program (SBP) benefits, and civilian employees seeking correction of military records other than those
related to civilian employment, who feel that they have suffered an injustice as a result of error or injustice in military records may apply to their respective
Boards for Correction of Military (or Naval) Records (BCMR/BCNR) for a correction of their military records. These Boards are the highest level appellate review
authority in the military. Therefore, applicants must exhaust all other administrative correction and appeal procedures before applying to the Boards.
This form collects the basic data that the Boards need to process and act on the request. Type or print all entries for all applicable items. If the item is not
applicable, enter "NA." If the space provided is insufficient, attach an extra page.
SECTION 3, ITEM 12. State the specific correction of record and all relief desired. If possible, identify exactly what document or information in your record you
believe to be erroneous or unjust and indicate what correction you want made to it. For additional errors or injustices, use Section 8.
ITEM 14. To justify correction of a military record, you must explain and show to the satisfaction of the Board that the alleged entry or omission in the record is in
error or unjust.
ITEM 15. U.S. Code, Title 10, Section 1552(b), states that no correction may be made unless the request is made within three years after the discovery of the
error or injustice, but the Board may excuse failure to file within three years in the interest of justice.
ITEM 16. Indicate whether you attribute the error or injustice to your involvement in a particular war or contingency operation.
ITEM 17. A hearing is not required to ensure the Board's full and impartial consideration of your application. If the Board decides that a hearing is warranted,
you, your witnesses, and your counsel may attend at no expense to the government, except that counsel may be provided if the Inspector General has reported
reprisal against you.
SECTION 4. You are responsible for obtaining and submitting clear, legible evidence to persuade the Board to grant your request, including any evidence that is
not already in your military record. Do not assume a document is in your record. Your evidence should be submitted with this form and may include, for example,
military records and orders, witnesses' sworn affidavits, and a brief of arguments supporting your request. List your evidence in item 19 and, if your case involves
a medical condition, submit relevant medical records and VA rating decisions as noted in item 20. Do not send irreplaceable original documents because they
will not be returned.
SECTION 5. The person whose record will be corrected if relief is granted must sign this form in Section 7. If that person is deceased or incompetent to sign, a
lawful claimant, such as a spouse, widow(er), next of kin (child, parent, or sibling), or legal representative, may sign the form. Proof of death, incompetency, or
power of attorney must be submitted. Former spouses may apply as claimants for SBP issues
.
SECTION 6. You may want counsel if your case is complex. Some veterans and service organizations furnish counsel without charge. Contact your local post or
chapter.
For detailed information on application and Board procedures, see: Army Regulation 15-185 and www.arba.army.pentagon.mil; Navy - SECNAVINST.5420.193
and www.hq.navy.mil/bcnr/bcnr.htm; Air Force Instruction 36-2603, Air Force Pamphlet 36-2607, and www.afpc.randolph.af.mil/safmrbr; Coast Guard - Code of
Federal Regulations, Title 33, Part 52 and www.uscg.mil/Resources/legal/BCMR.
MAIL COMPLETED APPLICATIONS TO APPROPRIATE ADDRESS BELOW
ARMY
Army Review Boards Agency
251 18th Street South, Suite 385
Arlington, VA 22202-3531
http://arba.army.pentagon.mil
NAVY AND MARINE CORPS
Board for Correction of Naval
Records
701 S. Courthouse Rd, Suite 1001
Arlington, VA 22204-2490
http://www.secnav.navy.mil/mra/bcnr
/Pages/default.aspx
AIR FORCE
Air Force Board for Correction of
Military Records
3351 Celmers Lane
Joint Base Andrews, MD 20762-6435
http://www.afpc.af.mil/Board-for-
Correction-of-Military-Records/
COAST GUARD
DHS Office of the General Counsel
Board for Correction of Military
Records, Stop 0485
2707 Martin Luther King Jr. Ave. S.E.
Washington, DC 20528-0485
https://www.uscg.mil/Resources/lega
l/BCMR/
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 the burden estimate or burden reduction
suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. 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.
RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS ON PAGE 3.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 1552, Correction of military records: claims incident thereto; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To initiate an application for correction of military record. The form is used by Board members for review of pertinent information in making a determination
of relief through correction of a military record. Completed forms are covered by correction of military records SORNs maintained by each of the Services or the Defense Finance and
Accounting Service.
ROUTINE USE(S): The DoD Routine Uses can be found in the applicable system of records notices below:
Army (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569931/a0015-185-sfmr.aspx)
Navy and Marine Corps (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570411/nm01000-1/)
Air Force (https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569833/f036-safcb-a/)
Defense Finance and Accounting Service (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570192/t7340b/)
Coast Guard (https://www.gpo.gov/fdsys/pkg/FR-2013-10-02/html/2013-23991.htm)
Official Military Personnel Files:
Army (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570054/a0600-8-104-ahrc.aspx)
Navy (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570310/n01070-3/)
Marine Corps (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570626/m01070-6/)
Air Force (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Article-View/Article/569821/f036-af-pc-c/)
Coast Guard (http://www.gpo.gov/fdsys/pkg/FR-2011-10-28/html/2011-27881.htm)
DISCLOSURE: Voluntary. However, failure by a claimant to provide the information not annotated as “optional” may result in a denial of your application. A claimant's SSN is used to
retrieve these records and links to the member's official military personnel file and pay record.
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