APPLICATION FOR CERTIFIED COPY
Type of copy (check one) _________ Certified _________ Photocopy
NAME OF VETERAN _________________________________________________________
Birth date of Veteran _______________________________________
Relationship of the Person/Agency receiving this copy to the person named on the record:
________ Self _____ Immediate Family – relationship _____________________________
Authorized Agent or Representative: (check one) _____ POA _____ Funeral Director
_____ Attorney ______ Other: ________________________________
_____ 75-year old record _________ ordered by court
_____ required by federal or state government or political subdivision (VA Director, etc.)
Reason for needing this copy:
__________________________________________________
__________________________________________________________________________
Applicant’s signature Day telephone number
Name and address of person receiving this copy (REQUIRED)
Name: ___________________________________________________________________
Street Address _____________________________________________________________
City, State, Zip _____________________________________________________________