2. Authorization to Record/Request Copy of Military Discharge Document
4. I, the undersigned, do hereby swear or affirm that I am the proper person within GS 47-113.2(b) to authorize _______________________________, serving as authorized agent or representative, to (record) (request a copy of) the military discharge document for ___________________________ (veteran's name). I hereby request that the Register of Deeds (record) (issue an uncertified copy of) (issue certified copy of) the military discharge document for the above named veteran for/to the bearer of this authorization.
6. This ___ day of __________, 20____.
8. __________________________________________________________
10. (Signature of Veteran, veteran's widow/widower, power of attorney, or veteran's executor)
12. Subscribed and Sworn to before me this _____________ day of ________________, 20_____
14. ______________________________________________Notary Public
16. My Commission expires: ________________________________
17. SEAL
Leave This Blank:


18. Print Only

* indicates a required field