NDVA - SFN 54412 REQUEST FOR RELEASE OF PRIVATE DATA

This authorization gives express authority to the County Recorder/Veterans Service Officer or North Dakota Department of Veterans Affairs, named above, to release a copy of the DD 214, or other private data held by the department of veteran identified in this release.
Provision of State Data Practices Act under North Dakota Statute
1. Information collected through use of this release may be used and disseminated only to individuals or agencies specifically authorized access to that data by state, local or federal law subsequent to the collection of that data.
2. You may refuse to sign this release of information, but such refusal will result in a denial of your request for record.
3. This release of information is valid for this request only.
VETERAN'S IDENTIFYING INFORMATION

Note: If the veteran's name has changed since the requested separation document was issued, provide evidence of the name change, such as marriage certificate, divorce decree, court ordered name change, adoption record, etc. Name of Veteran
Name of Veteran*
Veteran's Social Security or Service Number*
Date of Birth*

MonthDayYear
Date
Date of Death

MonthDayYear
Date
Date of Entry

MonthDayYear
Date
Date of Separation

MonthDayYear
Date
Branch

DATA ON PERSON REQUESTING INFORMATION (Please print clearly or type)
Requesters Name (Last, First, Middle)*
Address*

Address

Street Address Line 2

CityState

ZIP Code
Telephone Number*
Fax Number
Email Address
example@example.com
Relationship to Veteran (in the case of a deceased veteran)*
We must have written consent of next of kin. The next of kin is defined as: unremarried widow or widower, son, daughter, father, mother, brother or sister.
Information provided on this form is true and accurate to the best of my knowledge.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Return Completed Form to:

Department of Veterans Affairs
The Veteran's social security number is requested to enable the ND Department of Veterans Affairs to conduct a check for VA Benefits and to verify military service pursuant to N.D.C.C. sections 37-14-01.1 and 37-14-14. The individual's social security number will be used as an identification number. Disclosure of your social security number is mandatory. If you do not provide your social security number, the ND Department of Veterans Affairs will be unable to verify required information and fulfill your request.
Please verify that you are human*
Should be Empty: