Hugh Nguyen
Orange County Clerk-Recorder
P.O. Box 238, Santa Ana, CA 92702
County Administration South
630 N. Broadway, Santa Ana, CA 92701
Application for Certified Copy of DD-214
(May be use for request Via Mail – Mail your request to address above)
To obtain a certified copy of a DD-214 you must
be authorized under section 6107 of the Government Code
Please Print or Type Clearly – Use Black Ink Only
Requestor’s Information
Please check which box best describes how you are an authorized person to receive a certified copy of the DD-214 being requested
I am the person who is subject of the record I am a United States official.
I am a family member or legal representative of the person who is subject of the record (must present proper identification)
I represent a County office that provides veterans benefits upon written request of the office.
Requested by: ________________________________________ Requestor’s Phone Number: __________________
(type your full name)
Mail Copies to: _________________________________________________________________________________________
Address and apt. # if needed City State Zip Code
Veteran’s Information
Veteran’s Date of Discharge: ______________ Number of copies requested:________
_________________________ __________________________ __________________________
Veteran’s First Name(s) Veteran’s Middle Name(s) Veteran’s Last Name(s)
I ________________________________ swear under penalty of perjury that I am
an authorized person, as defined in California
(requestor’s full name)
Government Code Section 6107 and am eligible to receive a certified copy of the DD-214 identified on this application/form.
Sworn this _______day of ____________________, 20_____ at _____________________
(day) (month) (year) City
___________________________________________
Signature (If mailing, you must sign before a Notary Public)
This section must be completed for all mail requests.
State of _______________
County of_______________
On ______________________before me, ________________________________, personally appeared ____________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s) or the entity upon
behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the forgoing
paragraph is true and correct. WITNESS my hand and official seal.
_____________________________________ (SEAL)
(N
otary Signature)
For office use only:
Photo I.D. type:________________ I.D. # ________________ Book: _____ Page:_____ Document #:____________________
Rev 11/2019
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to
which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
