Supplemental D.V.S.S.E/V.S.S.
Information February 2007
SUPPLEMENTAL FORM FOR PEACEKEEPING MISSIONS
This form is in addition to the Form DD-214,
Armed Forces of the United States Report of Transfer or Discharge,
where the DD-214 is not specific about participation in a Peacekeeping Mission.
All Peacekeeping Missions have the added provision that the Veteran must have one of the following types of service for a total
of 14 days. The 14 day requirement is waived where a service injury was received in a combat zone in favor of actual time
served in a combat zone though less than 14 days.
1. Service in the specific country for the Peacekeeping Mission, OR
2. Service on board any ship actively engaged in patrolling the territorial waters of the specific country for the
Peacekeeping Mission, OR
3. Service in the airspace above the Republic of Bosnia and Herzegovina.
If Active Wartime Service Period indicated on Form V.S.S., Veteran/or Surviving Spouse/Surviving Civil Union
Partner/Surviving Domestic Partner of a Veteran or Serviceperson. Claim For Property Tax Deduction or Form D.V.S.S.E.,
Claim For Property Tax Exemption on Dwelling House of Disabled Veteran or Surviving Spouse/Surviving Civil Union
Partner/Surviving Domestic Partner of Disabled Veteran or Serviceperson is a Peacekeeping Mission, please provide the
following information regarding that service:
1. CLAIMANT NAME
__________________________________________________________________________________________
Name Of Claimant Owner
2. CLAIMED PROPERTY LOCATION
____________________________________________________________________________________________________________
Street Address Unit #, if Co-Op Telephone Number
____________________________________________________________________________________________________________
County Municipality
_______________________________________________________________________________________________________________________________________
Block Lot Qualifier
____________________________________________________________________________________________________________
Mailing Address if different from Claimed Property Location
3. SERVICE IN THE SPECIFIC COUNTRY
Name of the Country __________________________________________________________________
Actual Dates of Service in the Combat Zone _______________________________________________
4. SERVICE ON BOARD A SHIP
Name of the Vessel ___________________________________________________________________
Name of Territorial Waters Patrolled _____________________________________________________
Actual Dates of Service Patrolling the Waters ______________________________________________
5. SERVICE IN AIRSPACE
Name of the Country __________________________________________________________________
Actual Dates of Service in Combat Airspace________________________________________________
I certify the above declarations are true to the best of my knowledge and belief and understand they will be considered as
if made under oath and subject to penalties for perjury if falsified.
__________________________________________________________________________________________
Signature of Claimant Date
Additional proofs for the requirement of Active Wartime Service may be:
1. Military Certificate indicating your participation in the Mission and the actual dates of service.
2. Deployment Orders
3. Pay stubs indicating endangerment pay for the time period required.
4. Letter from Military Officer on official letterhead indicating the location, date and type of service.
5. Any other official document to support your claim.
