Revised 09-25-2017 AWages Full Civilian Background Packet Pg. 26 of 30
Standard Form 180 (Rev. 11/2015) (Page 1)
Prescribed by NARA (36 CFR 1233.18(d))
Authorized for local reproduction
Previous editions 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)
5. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.)
BRANCH OF SERVICE
ENTERED
RELEASED
OFFICER ENLISTED
(If unknown write “unknown”)
a. ACTIVE
☐ ☐
b. RESERVE
☐ ☐
NATIONAL
☐ ☐
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 214 Form 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 dated 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):
ALL DOCUMENTS IN OFFICIAL MILITARY PERSONNEL FILE (OMPF)
(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 Program ☐Medical ☐Genealogy ☐Correction ☐Personal ☐Other (explain)
PRE-EMPLOYMENT BACKGROUND INVESTIGATION
SECTION III – RETURN ADDRESS AND SIGNATURE
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 instructions sheet.)
☐OTHER
(Relationship to deceased Veteran)
3. SEND INFORMATION/DOCUMENTS TO:
(Please print of 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 id required if the request is for archived records.)
NEVADA DPS, BACKGROUNDS INVESTIGATION UNIT
Signature Required – Do Not Print
* 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.*