Fillable Military Record Application Form applicationmilitary

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Military Record Application Form applicationmilitary

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MILITARY RECORD COPIES
Copies of military records on file in our office, including the DD Form 214, Report of Separation (or
equivalent), can be made available upon request. Veterans and next-of-kin of deceased veterans
have the same rights to full access to the record. Next-of-kin are the unremarried widow or widower,
son or daughter, father or mother, brother or sister of the deceased veteran.
To obtain a copy of your Military Record, please fill out the attached application, along with a copy of
your driver’s license or military ID card and send to:
Polk County Recorder
Attn: Microfilm
111 Court Ave Ste 250
Des Moines, IA 50309-2251
Application for Certified Copy or Photocopy of Military Record
Type of copy (check one) _________Certified _________ Photocopy
Name of Veteran _________________________
Birth date of Veteran ______________________
Relationship of the Person/Agency Receiving This Copy to the Person Named on the Record:
_______ Self
_______ Immediate Family – Relationship: ________________
Authorized Agent or Representative: (check one)
_______ POA
_______ Funeral Director
_______ Attorney
_______ Other: ______________________
Reason for needing this copy:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Applicant’s Signature Day phone #
Name and Address of Person Receiving this copy (REQUIRED)
Name: _________________________________________________________________
Street: _________________________________________________________________
City, State, Zip: __________________________________________________________
Polk County Recorder◆111 Court Ave Ste 250◆Des Moines, Iowa 50309-2251◆515-286-3160
Julie M. Haggerty
Polk County Recorder
Registrar of Vital Records
Valeria J. Mason, 1
st
Deputy
www.polkrecorder.com
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Military Record Application Form applicationmilitary

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Completed 28 June 2020

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