Free September 19, 2003 - Indiana

REQUEST AND CONSENT FOR MILITARY DISCHARGE
State Form 52347 (8-05)

STATE OF INDIANA DEPARTMENT OF VETERANS AFFAIRS 302 West Washington Street, Room E120 Indianapolis, IN 46204-2738

REQUEST AND CONSENT FORM FOR MILITARY DISCHARGE PAPERS

This form does not authorize the release of information other than specifically described. Disclosure is voluntary. However, if information is not furnished, we may not be able to comply with your request. This written request includes express consent to release your social security number which is contained on the document to the individual authorized below. I have _______/have not______ made a written or telephonic request to this office prior to the submission of this release form.
VETERANS NAME: ______________________________________________________ SOCIAL SECURITY _______________________BRANCH OF SERVICE_____________ SERVICE NUMBER_______________________DATE OF BIRTH___________________ DATES OF SERVICE_______________________________________________________

To whom this information is authorized to be released? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Signature of the Veteran or his Power of Attorney or Next of Kin _______________________________________ Date of Release _________________

Phone: (317) 232-3910, Toll-Free (800) 400-4520 · Fax: (317) 232-7721

Website Address: www.in.gov/veteran