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MICHIGAN VETERANS AFFAIRS AGENCY P.O. Box 30104 Lansing, (City of Wyoming)

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MICHIGAN VETERANS AFFAIRS AGENCY
P.O. Box 30104
Lansing, MI 48909
800-MICH-VET (800-642-4838)
Fax: 517-284-5297
Email: MVAAResourceCenter@michigan.gov
Request for Record of Active Military Service (DD Form 214)
Name*:______________________________________________________________________________
S.S.N.*: ________________________________ Service No. (if applicable):_______________________
Date of Birth*: __________________________
Era: __________________________
Signature*:________________________________________________________________________
REQUIRED: A DD-214 can be requested by the veteran, next of kin or surviving spouse. If the veteran is deceased, the
request must be accompanied by a copy of the death certificate. If the veteran is alive and the signature is not the
veteran’s, the request must be accompanied by a POA.
Requested by:
Name*: ____________________________________________________________________________
Address*:___________________________________________________________________________
_
________________________________________________________
____________________
____________________________________________________________________________
Phone*: ____________________________________________________________________________
E-mail: ___________________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________________________
Required Information*
Rev. May 2017
Branch:________________________
Active
Guard
Reserve
Purpose of Request:
Is the veteran deceased?
Yes
No
By signing this document I declare under penalty of perjury under the laws of the United States of America that
the information provided in this document is true and correct.
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MICHIGAN VETERANS AFFAIRS AGENCY P.O. Box 30104 Lansing, (City of Wyoming)

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Completed 17 July 2020

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