Form DD Form 372 DD Form 372 Request for Verification of Birth

1. DATE OF REQUEST
(YYYYMMDD)

REQUEST FOR VERIFICATION OF BIRTH

OMB No. 0704-0006
OMB approval expires

When Section I is completed, the information contained on this form is protected by
the Privacy Act of 1974, as amended.

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0006). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE ADDRESS
LISTED IN SECTION III, ITEM 14.b.

N E E D S

SECTION I (Fill in every item in this section)

2. FULL NAME OF CHILD AT TIME OF BIRTH (Last, First, Middle Names)

D D
3. SEX (X)
MALE

6 7

4. DATE OF BIRTH
(YYYYMMDD)

FEMALE
5. PLACE OF BIRTH
a. CITY

b. COUNTY

c. STATE

6. FULL NAME OF FATHER AT TIME OF BIRTH OF CHILD LISTED IN BLOCK 2 (Last, First, Middle Names)

7. FULL NAME OF MOTHER AT TIME OF BIRTH OF CHILD LISTED IN BLOCK 2 (Last, First, Middle and Maiden Names)

8. RECRUITING OFFICER/REPRESENTATIVE MAKING REQUEST
a. NAME (Last, First, Middle Initial)
b. RANK/GRADE

c. TITLE

d. SIGNATURE

SECTION II (For use by Vital Statistics Department only)
9. CORRECTIONS OF ABOVE STATEMENT MADE ACCORDING TO FACTS ON FILE BY:
a. NAME (Last, First, Middle Initial)
b. ORGANIZATION

ORGANIZATION ADDRESS:
c. STREET

d. CITY

This is to verify that the above data as corrected are true and correct according
to the record on file in this office. These data are confidential and cannot be
used in any manner except for official purposes.

e. STATE

f. ZIP CODE

10. CERTIFICATE NUMBER 11. FILE DATE (YYYYMMDD)

12. VERIFIED BY (Signature)

13. DATE SIGNED
(YYYYMMDD)

SECTION III (For completion by recruiting office)
14. RECRUITING OFFICE IDENTIFICATION DATA
a. RECRUITING OFFICER/REPRESENTATIVE NAME (Last, First, Middle Initial)

b. UNIT/COMMAND NAME AND MAILING ADDRESS (Street, City, State and ZIP Code)

c. RECRUITER SIGNATURE

DD FORM 372, 20101018 DRAFT

d. DATE SIGNED
(YYYYMMDD)
PREVIOUS EDITION IS OBSOLETE.

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