Fillable Taxsettle Native American Veterans Income Tax Settlement (Kaibab Band of Paiute Indians)

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Taxsettle Native American Veterans Income Tax Settlement (Kaibab Band of Paiute Indians)

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Arizona Native American Veterans who served
on active duty in the U.S. Armed Forces during
1977 to 2005, may be eligible for an Arizona
state income tax refund. This fund includes
all living and deceased AZ Native American
Veterans.
Arizona Department of Veterans’ Services may
not accept claims after December 31, 2019.
So act now to submit your application form.
For more information, please contact the Hopi
Veterans Services at (928) 734-3461 to obtain
the application. Or download the application
on-line at www.dvs.az.gov to begin your claim.
Arizona Department of Revenue Pub 706 August 2017
This publication issued jointly by the Arizona Department of
Revenue and the Arizona Department of Veterans’ Services
is intended to provide general information about the Native
American Veterans Income Tax Settlement Fund. For
complete details, refer to Arizona Laws 2016, Chapter 125,
§ 19-29. In the case of inconsistency or omission in this
publication, the language of the Arizona law will prevail.
Background
On November 22, 2000 the United States Justice
Department issued a memo declaring that the taxation and
withholding of state income taxes from active duty military
pay of Native Americans domiciled on their reservation was
impermissible. The United States Department of Defense
began mandatory Arizona income tax withholding on all
active duty military pay on September 1, 1993 and continued
withholding Arizona income tax through December 31,
2005. Beginning January 1, 2006 Arizona no longer taxed
active duty military pay and therefore discontinued state
income tax withholding on this type of income. The Native
American Veterans Income Tax Settlement Fund was
established on July 1, 2016 to refund Arizona income tax
erroneously withheld from Native Americans who served in
the military while claiming tribal land as their domicile from
September 1, 1993 through December 31, 2005. During
the 2017 Arizona legislative session House Bill 2158 was
introduced to amend the original legislation when it was
discovered the Department of Defense may have withheld
Arizona income tax prior to September 1, 1993. Effective
August 9, 2017 refunds may be claimed for years 1977
through 2005.
Q1. Why was the Native American Veterans Income Tax
Settlement Fund established?
A1. Arizona income tax may have been withheld from
Native American active duty military pay in years
1977 through 2005. Those tax years are currently
closed by the statutes of limitations. Therefore, in an
effort to refund Arizona income tax withholding from
active duty military pay of Native Americans veterans
domiciled on their reservation, the Arizona legislature
established the Native American Veterans Income
Tax Settlement Fund.
Q2. What years did the Department of Defense withhold
Arizona income tax from active duty military pay?
A2. The Department of Defense may have withheld
Arizona income tax from 1977 through 2005.
Arizona entered into an agreement with the United
States Department of Defense to withhold Arizona
income tax from active duty military pay beginning
September 1, 1993. Arizona continued to withhold
income tax on active duty military pay through
2005. Beginning January 1, 2006 Arizona no longer
subjected active duty military pay to its income tax
and accordingly stopped withholding state income
tax. After the Native American Veterans Income Tax
Settlement Fund was established it was discovered the
Department of Defense may have withheld Arizona
income tax prior to September 1, 1993. As a result,
the Native American Veterans Income Tax Settlement
Fund was amended to allow refunds for years 1977
through 2005.
Q3. How much money is allocated to the Native American
Veterans Income Tax Settlement fund?
A3. The Arizona Legislature allocated two million dollars
to fund. Of the two million dollars 5 percent is
allocated to the Department of Veterans’ Services and
5 percent is allocated to Department of Revenue to
cover administrative costs.
Q4. What years are refunds available?
A4. Refunds may be claimed for years 1977 through 2005.
Mandatory withholding of Arizona income taxes by
the Department of Defense on active duty military pay
did not begin until September 1, 1993, however there
may have been withholding prior to that date.
Q5. May I amend my old Arizona state income tax returns
to recover my Arizona income tax withholding for
years 1977 through 2005?
A5. No, 1977 through 2005 are closed tax years under
Arizona’s statute of limitations. The only way to
recover withholding from tax years 1977 through
2005 is by making a claim under the Native American
Veterans Income Tax Settlement Fund.
Q6. How long is the Native American Veterans Income
Tax Settlement Fund open?
A6. The Native American Veterans Income Tax Settlement
Fund was established July 1, 2016. The Department
of Veterans’ Service may not accept claims after
December 31, 2019. The Department of Revenue will
not grant refunds after June 30, 2021. Any money
Arizona Department of Revenue azdor.gov
& Arizona Department of Veterans’ Services azdvs.gov
Native American Veterans Income Tax
Settlement Fund
Pub 706
Revised: August 2017
Arizona Department of Revenue Pub 706 August 2017
left in the Native American Veterans Income Tax
Settlement Fund on July 1, 2021 will be swept into the
general fund.
Q7. What does the claimant have to demonstrate?
A7. Produce DD-214 or other proof of military service
provided by the United States Department of Defense,
B. Sign a statement declaring they were an enrolled
member of their tribe while serving in the military,
C. Produce evidence of domicile while serving in the
military, D. Show Arizona income tax was withheld
(W-2) and E. Sign a statement that the Arizona
income tax was not refunded.
Q8. What must a claimant do in addition to the general
requirements if the veteran is deceased?
A8. In addition to the requirements listed in Question
and Answer #7 above, a claimant who is a surviving
spouse or personal representative must produce the
veteran’s death certificate to make a claim. A personal
representative must also sign a statement confirming
they are the decedent’s personal representative and
produce a copy of the claimant’s appointment. If
the claimant is a not a surviving spouse or personal
representative they must sign a statement that the
estate is worth less than $30,000, that 30 days have
passed since the decedent’s death and that they are the
rightful successor.
Q9. How does the application process work?
A9. The claimant sends their completed forms along
with any relevant paper work to the Department of
Veterans’ Services. Veterans’ Services has 210 days
to accept or reject the claim. Claims accepted by
the Department of Veterans’ Services are then sent
to the Department of Revenue. The Department of
Revenue has 210 days to approve or reject claims. The
Department of Revenue will issue refunds to claimants
with valid claims.
Q10. What forms are used to make a claim?
A10. Arizona Form NASF is used for general claims,
Arizona Form NASF-D is an additional form for
claimants if the veteran is deceased and Arizona Form
NASF-RS is a form used to substantiate the veteran’s
residency.
Q11. Where do I find the application forms?
A11. The application forms are available to download
online at https://dvs.az.gov or https://www.azdor.gov
Q12. Where do I mail my completed forms?
A12. Arizona Department of Veterans’ Services
Attention: NASF
3839 N. 3rd Street, Suite 209
Phoenix, AZ 85012
Q13. Who may make a claim?
A13. Native American veterans who had Arizona income
tax withheld from their active duty military pay
while domiciled on their reservation. If the veteran
is deceased the surviving spouse or personal
representative may make a claim. If anyone other than
the surviving spouse or personal representative (e.g.,
child of the veteran) makes a claim they must show
the value of decedent’s estate was less than $30,000.
Q14. How are claims paid?
Q14. On a first-come, first-served basis until the fund is
exhausted.
Q15. Is interest paid on the refunds?
A15. Yes, settlement payments shall include interest
computed on a daily basis from the date of a timely
filed return.
Q16. Are refunds subject to setoffs?
A16. Yes, the refunds are subject to setoffs consistent with
A.R.S. § 42-1122. Examples of setoffs would include
back taxes, overdue child support and unpaid court
fees.
Q17. What if I do not have my DD-214 or other proof of
military service?
A17. Arizona Form NASF includes a check box allowing
the claimant to authorize the Arizona Department of
Veterans’ Services to obtain their DD-214 or other
proof of military service on their behalf from the
United States Department of Defense. Please attach
and sign Form SF-180 and attach it to your application.
Q18. What if I do not have my old W-2’s?
A18. Arizona Form NASF includes a check box allowing
the claimant to authorize the Arizona Department
of Revenue to obtain prior year W-2’s on their behalf
from the United States Department of Defense.
Q19. What if I had Arizona withholding from my active
duty military pay while I was domiciled on my
reservation, but did not file an Arizona income tax
return for those years?
A19. Even if you did not file an Arizona return during those
years you are still eligible for a refund of your active
duty military pay withholding including accrued
interest, however any refunds paid are subject to
setoffs consistent with A.R.S. § 42-1122.
Q20. What if my claim is denied?
A20. If the claim is denied by the Arizona Department of
Veterans’ Services the appealed case will go to the
Office of Administrative Hearings. If the claim is
denied by the Department of Revenue the appealed
case will be considered a contested case heard by the
Department of Revenue’s Hearing Officer.
Arizona Department of Revenue Pub 706 August 2017
Q21. What is the status of my refund claim?
A21. If the application for refund is still being processed at
Arizona Department of Veterans’ Services the contact
information is
Arizona Department of Veterans’ Services
Attention: NASF
3839 N 3rd Street, Suite 209
Phoenix, AZ 85012
Phone Number: 602-234-8432
Email Address: NASF@AZDVS.GOV
If the application for refund is being processed by
the Arizona Department of Revenue the contact
information is
Arizona Department of Revenue
Attention: NASF
1600 W Monroe, Mail Code 1400
Phoenix, AZ 85007-2650
Phone Number: 602-716-6027
Email Address: NASF@azdor.gov
This publication is available in an alternative format upon request.
ADOR 11305 (8/17) Page 1 of 2
Please complete this application for a settlement payment if you are a Native American Veteran who maintained a home on tribal land during your military
service between the years 1977 - 2005 and had Arizona income tax withheld on any of your active duty military pay.
Mail completed Form NASF, Native American Veterans Income Tax Settlement Fund Claim, and attachments to:
Arizona Department of Veterans’ Services
Attention: NASF
3839 N. 3rd Street, Suite #209
Phoenix, AZ 85012
Telephone number: Arizona Department of Veteran Services: (602) 234-8432 Arizona Department of Revenue: (602) 716-6027
Part 1 Veteran’s Information
Veteran’s First Name and Middle Initial Last Name Social Security Number
Name of Veteran as indicated on DD Form 214 (if different) Veteran’s Phone Number
Address Veteran’s Email Address
City State ZIP Code
Part 2 Veteran Status as a Native American
Name of Arizona Federally Recognized Indian Tribe of which the Veteran
or Spouse is an Enrolled Member
Spouse’s Name (if spouse is an enrolled member)
Part 3 Military Service
Enter the branch of service and the dates of active duty in the Armed Forces of the United States. To verify the active duty period, attach Form(s) DD Form
214 and mark the box below indicating that the form(s) is attached or mark the box to authorize the Department of Veterans’ Services to request a copy
of the form from the Department of Defense.
Branch of Service
Date of Military Service (Between 1977-2005)
From To
Check One:
DD Form 214 is attached, or
I completed and signed Form SF-180 authorizing the Department of Veterans’ Services to request a copy of the claimant’s DD Form 214 from the
Department of Defense.
Please Note: Failure to provide a DD-214 or SF-180 will result in the denial of the claim.
Part 4 Residency on Tribal Land during Period of Active Duty
Check One:
The address on DD Form 214 was the claimant’s (or claimant’s spouse’s) home of record address for the entire period of the claimant’s military
service covered by this claim, and is located on the tribal land to which the claimant or the claimant’s spouse is a member, or
The address on DD Form 214 was not the claimant’s (or claimant’s spouse’s) home of record address for the entire period of the claimant’s military
service covered by this claim, or is not located on tribal land to which the claimant or the claimant’s spouse is a member. A completed Arizona Form
NASF-RS, Native American Veterans Income Tax Settlement Fund Claim Residency Statement, is attached.
Part 5 Deceased Veteran (only complete if veteran is deceased)
Veteran’s Date of Death
M M D D Y Y Y Y
If the refund must be made payable to a person other than the veteran, enter the name and SSN of the person entitled to claim the refund. Otherwise,
the check will be made payable to the estate of the decedent.
Spouse, Other Successor, or Personal Representative’s First and Middle Initial Last Name Social Security Number
Check the following two boxes to indicate that the required document is attached:
Attach a copy of the death certificate or other proof of death. (An original or an authentic copy of a telegram or letter from the Department of Defense
notifying the next of kin of the decedent’s death will constitute proof of death.) Proof of death must be attached if the veteran is deceased.
Attach a signed and dated Arizona Form NASF-D, Claim for Refund on Behalf of Deceased Native American Veteran. Complete this form even if you
were the spouse of the veteran at the time of death.
Arizona Form
NASF
State of Arizona - Department of Veterans’ Services
Native American Veterans Income Tax Settlement Fund Claim
ADOR 11305 (8/17) Page 2 of 2
Part 6 Arizona Income Tax Withheld
In the columns below please enter each tax year in which Arizona income tax was withheld and the amount of Arizona income tax with held from income for active
military service during the year and reported on the federal Form W-2. Attach all federal Forms W-2. If you do not have a copy of your federal Forms W-2, or the
attached federal Forms W-2 do not represent all the tax withheld from active military service during a year, check the box in the third column to request Department of
Revenue obtain the claimant’s W-2 Form information from the Department of Defense. For each tax year listed, answer the question in the fourth column. The Native
American Veterans Income Tax Settlement Fund passed in 2016 allows refunds of Arizona income tax withholding from September 1, 1993 through December 31,
2005. In 2017, the Arizona legislature amended the Native American Veterans Income Tax Settlement Fund by extending the dates to claim a refund to July 1, 1977
(the earliest known date of any state income tax withholding on military compensation) after it was discovered there may have been Arizona income tax withholding
on military compensation prior to 1993. Effective August 9, 2017 claims for refund of Arizona withholding may be granted for tax years 1977 through 2005.
(1)
Tax Year
(1977 to 2005)
(2)
Amount of Arizona Income Tax Withheld
from the attached copy of Form W-2. (Enter
“Do not have W-2” if you do not have a
Form W-2 for this year.)
(3)
I request that the Department of Revenue
obtain the claimant’s Form W-2 information
for the tax year
(4)
To the best of my knowledge, I certify that a
refund for the taxes withheld was (check the
“Yes” box) or was not (check the “No” box)
received.
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
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Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
$
Yes
No
Yes
No
Total of column 2
$
Part 7 Signature of Claimant
Under penalty of perjury, I declare I have examined this application, including accompanying schedules, statements and attachments, and to the best of
my knowledge and belief it is true, correct, and complete.
Print Name of Veteran (if deceased, personal representative or legal successor) Signature Date
FOR DEPARTMENT of VETERANS’ SERVICE USE ONLY
Verication of Veteran’s Status by the Department of Veterans’ Services
The Department of Veterans’ Services has fulfilled their obligation under the Arizona Laws 2016, Chapter 125 § 19-29.
Print Name of Director of Department of Veterans’ Services or delegate Title
Signature Date
Your Name (as shown on page 1) Your Social Security or Employer Identification Number
Print Form
ADOR 11308 (1/17)
Purpose of This Form: A claimant for a settlement payment from the Native American Veterans Income Tax Settlement Fund must
substantiate residency on Indian tribal land during the period(s) any Arizona Individual income tax was withheld from active duty military
pay. The veteran must be a resident within the boundaries of the Indian member’s or the member’s spouse’s reservation or within the
boundaries of lands held in trust by the United States for the benet of the member or spouse or the member’s or spouse’s tribe. If the
address shown on the claimant’s DD Form 214 is not on tribal land, or the claimant cannot establish that the address is on tribal land, or
the address was not the claimant’s address of record for the entire period for which the claim is being made, the claimant must provide the
following statement signed by the claimant and attested by a tribal governor, president or designee of the governor or president.
Veteran’s Information
Veteran’s First Name and Middle Initial Last Name Social Security Number
Home of record (physical address or description)
during period of active duty military service
Dates of Residency
From:
M M D D Y Y
To:
M M D D Y Y
Indicate the name of the Indian Tribe in
which the address is located
From:
To:
From:
To:
From:
To:
Claimant
Under penalty of perjury, I declare that the address(s) listed above is the home of record established for the claimant (veteran) with the
Depart ment of Defense while in active duty military service.
Print Name of Veteran (if deceased, personal representative or legal successor) Signature Date
Tribal Governor, President or Designee of the Governor or President
Under penalty of perjury, I attest that each address or physical description of the location of the home of record listed above is located
on the Indian tribal land as indicated.
Print Name of Tribal Governor, President, or Designee Title
Signature Date
Arizona Form
NASF-RS
State of Arizona - Department of Veterans’ Services
Native American Veterans Income Tax Settlement Fund Claim
Residency Statement
INSTRUCTION AND INFORMATION SHEET FOR SF 180, REQUEST PERTAINING TO MILITARY RECORDS
1. General Information. The Standard Form 180, Request Pertaining to Military Records (SF180) is used to request information from military records.
Certain identifying information is necessary to determine the location of an individual's record of military service. Please try to answer each item on the SF
180. If you do not have and cannot obtain the information for an item, show "NA," meaning the information is "not available". Include as much of the
requested information as you can. Incomplete information may delay response time. To determine where to mail this request see Page 2 of the SF180 for
record locations and facility addresses.
Online requests may be submitted to the National Personnel Records Center (NPRC) by a veteran or deceased veteran’s next-of-kin using eVetRecs at
http://www.archives.gov/veterans/military-service-records/ .
2. Personnel Records/Military Human Resource Records/Official Military Personnel File (OMPF) and Medical Records/Service Treatment
Records (STR). Personnel records of military members who were discharged, retired, or died in service LESS THAN 62 YEARS AGO and medical
records are in the legal custody of the military service department and are administered in accordance with rules issued by the Department of Defense and
the Department of Homeland Security (DHS, Coast Guard). STRs of persons on active duty are generally kept at the local servicing clinic. After the last
day of active duty, STRs should be requested from the appropriate address on page 2 of the SF 180. (See item 3, Archival Records, if the military member
was discharged, retired or died in service more than 62 years ago.)
a. Release of information: Release of information is subject to restrictions imposed by the military services consistent with Department of Defense
regulations, the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The service member (either past or present) or
the member's legal guardian has access to almost any information contained in that member's own record. The authorization signature of the service
member or the member's legal guardian is needed in Section III of the SF180. Others requesting information from military personnel records and/or
STRs must have the release authorization in Section III of the SF 180 signed by the member or legal guardian. If the appropriate signature cannot be
obtained, only limited types of information can be provided. If the former member is deceased, the surviving next-of-kin may, under certain
circumstances, be entitled to greater access to a deceased veteran's records than a member of the general public. The next-of-kin may be any of the
following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. Requesters MUST provide proof of death, such as a
copy of a death certificate, newspaper article (obituary) or death notice, coroner’s report of death, funeral director’s signed statement of
death, or verdict of coroner’s jury.
b. Fees for records: There is no charge for most services provided to service members or next-of-kin of deceased veterans. A nominal fee is
charged for certain types of service. In most instances, service fees cannot be determined in advance. If your request involves a service fee, you will
receive an invoice with your records.
3. Archival Records. Personnel records of military members who were discharged, retired, or died in service 62 OR MORE YEARS AGO have been
transferred to the legal custody of NARA and are referred to as “archival records”.
a. Release of Information: Archival records are open to the public. The Privacy Act of 1974 does not apply to archival records, therefore, written
authorization from the veteran or next-of-kin is not required. In order to protect the privacy of the veteran, his/her family, and third parties named in
the records, the personal privacy exemption of the Freedom of Information Act (5 U.S.C. 552 (b) (6)) may still apply and may preclude the release
of some information.
b. Fees for Archival Records: Access to archival records are granted by offering copies of the records for a fee (44 U.S.C. 2116 (c)). If a fee applies
to the photocopies of documents in the requested record, you will receive an invoice. Photocopies will be sent after payment is made. For more
information see http://www.archives.gov/st-louis/archival-programs/military-personnel-archival/ompf-archival-requests.html.
4. Where reply may be sent. The reply may be sent to the service member or any other address designated by the service member or other authorized
requester. If the designated address is NOT registered to the addressee by the U.S. Postal Service (USPS), provide BOTH the addressee’s name AND “in
care of” (c/o) the name of the person to whom the address is registered on the NAME line in Section III, item 3, on page 1 of the SF 180. The COMPLETE
address must be provided, INCLUDING any apartment/suite/unit/lot/space/etc. number.
5. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; SERVICE TREATMENT RECORD (STR) -- The
chronology of medical, mental health, and dental care received by service members during the course of their military career (does not include records of
treatment while hospitalized); TDRL – Temporary Disability Retired List.
6. Service completed before World War I. National Archives Trust Fund (NATF) forms must be used to request these records. Obtain the forms by e-
mail from inquire@nara.gov or write to the Code 6 address on page 2 of the SF 180.
PRIVACY ACT OF 1974 COMPLIANCE INFORMATION
The following information is provided in accordance with 5 U.S.C. 552a(e)(3) and applies to this form. Authority for collection of the information is 44
U.S.C. 2907, 3101, and 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. If
the requested information is not provided, it may delay servicing your inquiry because the facility servicing the service member's record may not have all of
the information needed to locate it. The purpose of the information on this form is to assist the facility servicing the records (see the address list) in locating
the correct military service record(s) or information to answer your inquiry. This form is then retained as a record of disclosure. The form may also be
disclosed to Department of Defense components, the Department of Veterans Affairs, the Department of Homeland Security (DHS, U.S. Coast Guard), or
the National Archives and Records Administration when the original custodian of the military health and personnel records transfers all or part of those
records to that agency. If the service member was a member of the National Guard, the form may also be disclosed to the Adjutant General of the
appropriate state, District of Columbia, or Puerto Rico, where he or she served.
PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
Public burden reporting for this collection of information is estimated to be five minutes per request, including time for reviewing instructions and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to National Archives and Records Administration (ISSD), 8601 Adelphi Road, College Park, MD 20740-
6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE APPROPRIATE ADDRESS LISTED ON
PAGE 2 OF THE SF 180.
Standard Form 180 (Rev. 07/2015) (Page 1) Authorized for local reproduction
Prescribed by NARA (36 CFR 1233.18 (d)) Previous edition unusable OMB No. 3095-0029 Expires 04/30/2018
REQUEST PERTAINING TO MILITARY RECORDS
Requests from veterans or deceased veteran’s next-of-kin may be submitted online by using eVetRecs at http://www.archives.gov/veterans/military-service-records/
To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW.
SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible.)
1. NAME USED DURING SERVICE (last, first, full middle)
3. DATE OF BIRTH
4. PLACE OF BIRTH
5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.)
BRANCH OF SERVICE
DATE ENTERED
DATE RELEASED
OFFICER
ENLISTED
SERVICE NUMBER
(If unknown, write “unknown”)
a. ACTIVE
b. RESERVE
c. STATE
NATIONAL
GUARD
6. IS THIS PERSON DECEASED?
NO YES -
MUST provide Date of Death if veteran is deceased:
7. DID THIS PERSON RETIRE FROM MILITARY SERVICE?
NO YES
SECTION II – INFORMATION AND/OR DOCUMENTS REQUESTED
1. CHECK THE ITEM(S) YOU ARE REQUESTING:
DD Form 214 or equivalent. Year(s) in which form(s) issued to veteran:
This form contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran’s next-of-kin, or other
persons or organizations, if authorized in Section III, below. An UNDELETED DD214 is ordinarily required to determine eligibility for benefits. If you
request a DELETED copy, the following items will be blacked out: authority for separation, reason for separation, reenlistment eligibility code, separation
(SPD/SPN) code, and, for separations after June 30, 1979, character of separation and dates of time lost.
An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box: I want a DELETED copy.
Medical Records Includes Service Treatment Records, Health (outpatient) and Dental Records. IF HOSPITALIZED (inpatient) the FACILITY NAME and
DATE (month and year) for EACH admission MUST be provided:
Other (Specify):
2. PURPOSE: (Providing information about the purpose of the request is strictly voluntary; however, it may help to provide the best possible response and may
result in a faster reply. Information provided will in no way be used to make a decision to deny the request.)
Benefits (explain)
Employment
VA Loan Programs
Medical
Genealogy
Correction
Personal
Other (explain)
Explain here:
SECTION III - RETURN ADDRESS AND SIGNATURE
1. REQUESTER NAME:
2.
I am the MILITARY SERVICE MEMBER OR VETERAN identified in Section
I, above.
I am the VETERAN’S LEGAL GUARDIAN (MUST submit copy of Court
Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit copy of
Authorization Letter or Power of Attorney)
I am the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit Proof of
Death. See item 2a on instruction sheet.)
OTHER
(Relationship to deceased veteran)
(Specify type of Other)
3. SEND INFORMATION/DOCUMENTS TO:
(Please print or type. See item 4 on accompanying instructions.)
4. AUTHORIZATION SIGNATURE: I declare (or certify, verify, or
state) under penalty of perjury under the laws of the United States of
America that the information in this Section III is true and correct and
that I authorize the release of the requested information. (See items 2a or
3a on accompanying instruction sheet. Without the Authorization Signature
of the veteran, next-of-kin of deceased veteran, veteran’s legal guardian,
authorized government agent, or other authorized representative, only
limited information can be released unless the request is archival. No
signature is required if the request if for archival records. )
Name
Street Apt.
______________________________________________________________
City State Zip Code
* This form is available at http://www.archives.gov/veterans-military-service-
records/standard-form-180.pdf on the National Archives and Records
Administration (NARA) web site. *
Signature Required - Do not print Date
( )
( )
Daytime phone
Fax Number
Email address
Arizona Department of Veterans Services, Attn:NASF
3839 North 3rd Street - Suite 209
Phoenix
AZ
85012
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Taxsettle Native American Veterans Income Tax Settlement (Kaibab Band of Paiute Indians)

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Completed 31 December 2022

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