13075 Questionnaire about Military Service

		OMB No. 3095-0039 Expires xx/xx/xxxx
		QUESTIONNAIRE ABOUT MILITARY SERVICE
		1. WHY WE ARE SENDING YOU THIS FORM: We cannot respond to your request at this time for one of the following reasons:
								We are unable to locate a record with the information provided in your original inquiry
						- or -
								The record needed to answer your inquiry was lost in the July 1973 fire that destroyed millions of records here at the National Personnel Records Center. The records stored in the area which suffered the most damage in the fire were those of:
									Army veterans discharged or deceased between November 1, 1912, and December 31, 1959
									Air Force veterans discharged, deceased, or retired before January 1, 1964, whose names come alphabetically after Hubbard, James E.
		The information you provide on page 2 of this form may help locate the record, if it is available; or, if the record is not available, it may enable the Center to make use of various alternate sources to reconstruct some of the basic service record data. Please note that if the only document you need is the Report of Separation (DD Form 214, WDAGO Form 53-55, etc.), it may be available from a former employer or from the recorder’s office of the city or county where the veteran lived just after separation/discharge.
		2. WHAT YOU NEED TO DO:
								Fill out page 2 of this form (NA Form 13075) as completely as possible, as well as any other form(s) you may have received with this one, such as Standard Form (SF) 180 and NA Form 13055;
								Attach copies of any papers you have that relate to the requested military service, such as military orders, award citations, and military addresses as shown on letters mailed home; and
								Send the above item(s) to the National Personnel Records Center at the address shown below or fax to (314) 801-9201195. If we do not receive this information from you within 30 days, your request will be closed without further reply.
		3. NOTE: Are you requesting military service medals only? If so, do you have a copy of the Report of Separation (DD Form 214, WDAGO Form 53-55, etc.) and other military papers that show which medals were earned? If you send such information about medals, you do not need to fill out this NA Form 13075; however, you must return page 2 (with the barcode) so that we can locate your original request. Finally, if possible, please send a list of the names and locations of all military units or “outfits” to which the veteran was assigned, including dates, while on active duty. This may help determine eligibility for “unit” awards.
		PRIVACY ACT OF 1974 COMPLIANCE INFORMATION The following information is provided in accordance with 5 U.S.C. 552a(e) (3) and applies to this form. Authority for collection of the information is 44 U.S.C. 2907, 3101, and 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. If the requested information is not provided, it may delay servicing your inquiry because the National Personnel Records Center may not have all of the information needed to locate the record(s) sought. The purpose of the information on this form is to assist the National Personnel Records Center in locating the correct military service record(s) or information to answer your inquiry. This form is then filed in the requested military service record as a record of disclosure. The form may be disclosed to the Department of Defense components or the Department of Homeland Security (DHS, U.S. Coast Guard), if the National Personnel Records Center transfers all or part of those records to such agency. If the service member was a member of the National Guard, the form may be disclosed to the Adjutant General of the appropriate state, District of Columbia, or Puerto Rico, where he or she served. The form may also be disclosed when the military service member or, in the case of a deceased service member, the military service department, authorizes a specific individual or organization to have access to the military service record. PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. The information requested on this form is being collected and used by the National Personnel Records Center to identify and locate military service records that could not be identified and located in response to the original inquiry. Public burden reporting for this collection of information is estimated to be five minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE ADDRESS BELOW.
															     
															Date
												Prepared by      
							     						NRPM    
													NATIONAL PERSONNEL RECORDS CENTER (Military Personnel Records) 9700 Page Avenue St. Louis, MO 63132-5100

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA FORM 13075 (Page 1 of 2) (REV. 12-05)

OMB No. 3095-0039 Expires xx/xx/xxxx

QUESTIONNAIRE ABOUT MILITARY SERVICE

Please complete this form to the best of your ability.

Name(s) used during service (and nicknames, if any): Last First Middle

Branch of Service: Army Air Force Navy Marine Corps Coast Guard

Veteran’s Social Security Number:

Date of Birth:

City and State (Country) of Birth:

Served as:

Serial/Service number(s):

Home Address:

Officer

When entered service:

Enlisted

City

County

State

If enlisted:

volunteered drafted

When released from active duty:

Final Rank:

City

County

State

Was service six months active duty for training only?

Yes No

Selective Service:

Local Board Number

City

State

Veteran’s Selective Service Number

Names of close relatives when military service began (parents, siblings, spouse, children):

Place of enlistment or induction (where veteran took oath of service, such as examining station, reception center, or place of basic training.) Show name of military facility, city, state:

Month/Day/Year began active duty:

Place of basic training and month/day/year began (if different from place and date shown on line above):

Type of military assignment (infantry, airborne, engineer, bombers, fighters, supply, maintenance, food service, etc.):

Last military organization and location (show full unit designations, such as army, division, regiment, battalion, company):

Separation Station (if this service member was released at a separation station after leaving the last “permanent” organization or “unit”, include location of separation station):

Month/Day/Year released from active duty

Month/Day/Year of any reenlistment(s) (include full designation and location of unit to which assigned at that time):

If this veteran is deceased, show date of death

Did the veteran ever:

a.

File a claim for VA benefits?

No Yes Don’t Know

If yes, show VA Claim Number:

b.

Serve in the Reserves after release from active duty period shown above?

No Yes Don’t Know

If yes, show branch of service

show mo/yr from

to

c.

Receive a state bonus for military service?

No Yes Don’t Know

If yes, show state

mo/yr paid

d.

Serve in the National Guard?

No Yes Don’t Know

If yes, show state

Army Air

show mo/day/yr from

to

e.

Retire from any military service branch?

No Yes Don’t Know

If yes, show branch of service

show mo/yr retired

f.

Spend time on the Temporary Disability Retired List (TDRL)?

No Yes Don’t Know

If yes, show branch of service

show mo/day/yr from

to

g.

Serve active duty in any other military service branch in later years?

No Yes Don’t Know

If yes, show branch of service

show mo/day/yr from

to

h.

Work for the Federal Government as a civilian?

No Yes Don’t Know

If yes, show agency name

show city/state

show mo/day/yr from

to

Purpose: (Optional – An explanation of the purpose of this request is strictly voluntary. Such information may help the National Personnel Records Center to provide the best possible response and will in no way be used to make a decision to deny the request.)

SIGNATURE:

TODAY’S DATE:

DAYTIME PHONE NUMBER: ( )



Before you send this form, please make sure you have followed the instructions in the “What You Need To Do” section on the other side, otherwise it may not be possible to service this request.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA FORM 13075 (Page 2 of 2) (REV. 12-05)