Form DD Form 2168 DD Form 2168 Application for Discharge of Member or Survivor of Membe

CUI (when filled in)

Prescribed by: DoDD 1000.20

APPLICATION FOR DISCHARGE OF MEMBER OR SURVIVOR OF MEMBER OF GROUP CERTIFIED
TO HAVE PERFORMED ACTIVE DUTY WITH THE ARMED FORCES OF THE UNITED STATES
(Read Instructions on back before completing form.)

OMB No. 0704-0100
OMB approval expires:
YYYYMMDD

The public reporting burden for this collection of information is estimated to average 30 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 the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at [email protected]. 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. SEND COMPLETED FORM TO THE APPROPRIATE SERVICE ADDRESS ON THE BACK OF THIS
PAGE.

PRIVACY ACT STATEMENT
AUTHORITY: Public Law 95-202, 91 Stat. 1433, Sec. 401, “GI Bill Improvement Act of 1977” as amended (see note to Section 106 of Title 38 United States Code), DoDD 1000.20,
Active Duty Service Determinations for Civilian or Contractual Groups; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To assist the Secretaries of the Armed Forces in determining if applicant was member of a group which has been found to have performed active military
service, and, after an affirmative finding as to the applicant, to assist the Secretary of an Armed Force in issuing an appropriate certificate of service.
ROUTINE USE(S): The information may be released to the civilian employer or contractual group or the Department of Homeland Security (for coast Guard applicants) to support the
member's claim. To the Department of the Veterans Affairs to provide substantiation for benefit eligibility. The Department of Justice in pending or potential litigation to which the record
is pertinent. Additional routine uses are listed in the applicable military personnel system of records notices:
Army (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570051/a0600-8-104b-ahrc/);
Navy (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570310/n01070-3/);
Marine Corps (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570626/m01070-6/);
Air Force (http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569821/f036-af-pc-c/); and
Coast Guard (http://edocket.access.gpo.gov/2008/E8-29793.htm)
DISCLOSURE: Voluntary; however, failure to provide identifying information may impede processing of this application. The use of Social Security Number is strictly to assure proper
identification of the individual and appropriate records.

I. GROUP MEMBER PERSONAL DATA
1.b. ALIAS(ES)

1.a. MEMBER'S NAME (Last, First, Middle and Maiden, if any)

4.a. PRESENT STREET ADDRESS
(Incl. apartment number)

b. CITY

II. SERVICE GROUP DATA TO SUPPORT CLAIM
5. NAME OF GROUP SERVED WITH

c. COUNTY

d. STATE

e. ZIP CODE

DRAFT

6. IDENTIFICATION NO.

a. DATE (YYYYMMDD)
9. ENTRY INTO SERVICE

3. DATE OF BIRTH
(YYYYMMDD)

2. SSN

8. HIGHEST PAY GRADE
(or actual pay)

7. HIGHEST GRADE/RANK/RATING HELD

b. PLACE (Include City and State of Military Installation)

a. DATE (YYYYMMDD)

b. PLACE (Include City and State of Military Installation)

10. ACTUAL MILITARY SERVICE BEFORE/AFTER THIS SERVICE
11. HOME OF RECORD AT TIME OF ENTRY
a. STREET ADDRESS (Incl. apartment number)

b. CITY

c. COUNTY

d. STATE

e. ZIP CODE

12. GRADE/RANK/
RATING AT TIME
OF ENTRY

14. SPECIALTY JOB TITLE(S)

13. MILITARY INSTALLATION WHERE ORDERED TO REPORT (Include City and State)

15. DECORATIONS, MEDALS, BADGES, COMMENDATIONS, CAMPAIGN RIBBONS AWARDED/AUTHORIZED

16. TERMINATION OF GROUP SERVICE (Separation, Discharge, Resignation, etc.)
a. TYPE OF TERMINATION

b. REASON

c. STATION BASE/LOCATION

e. DATE SERVICE TERMINATED
(YYYYMMDD)

d. SERVICE COMMAND
AFFILIATION

III. APPLICATION INFORMATION
Applicant must sign in the space provided. If the record in question is that of a person who is deceased or incompetent, legal proof of death or incompetency must accompany this
application. If the application is signed by the spouse, widow, widower, next of kin, or legal representative, give relationship or status in the appropriate box below.
17. RELATIONSHIP TO
APPLICANT (X one)

a. SPOUSE

b. WIDOW

c. WIDOWER

e. LEGAL
REPRESENTATIVE

d. NEXT OF KIN

f. OTHER (Specify)

I MAKE THE FOREGOING STATEMENTS, AS PART OF MY CLAIM, WITH FULL KNOWLEDGE OF THE PENALTIES INVOLVED FOR WILLFULLY MAKING A FALSE
STATEMENT OR CLAIM. (U.S. Code, Title 18, Sec. 287, 1001, provides a penalty of not more than $10,000 fine or not more than five years imprisonment or both.)
18. APPLICANT

d. MAILING STREET ADDRESS (Incl. apartment number)

c. DATE SIGNED
(YYYYMMDD)

b. SIGNATURE

a. NAME (Last, First, Middle)

CITY

STATE

ZIP CODE

f. TELEPHONE (Include area code)

IV. DISCLOSURE OF INFORMATION
19. I hereby authorize the release of copies of any official records maintained by the National Personnel
Records Center to the appropriate military personnel office (listed on the reverse side) for the purpose of
processing my application for discharge under Public Law 95-202

DD FORM 2168, MAR 2021
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

a. SIGNATURE

b. DATE SIGNED
(YYYYMMDD)

Controlled by: OUSD(P&R)
Page
CUI Category: PRVCY
Distribution/Dissemination Control: FEDCON
POC: [email protected]

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CUI (when filled in)
INSTRUCTIONS
1. Use typewriter or print information when completing this form. Submit in original copy only. Complete all items. If the question is not appropriate, write "NONE."
Attach all documentation available to support information you enter on the form.
2. The burden of proof is on the applicant to show he or she was part of the group that provided the recognized services. List all attachments or enclosures. Use
plain bond paper for additional explanation, if needed.
3. Include any supporting documents which support your claim. Supporting material may include, but is not limited to, separation discharge certificates, mission
orders, identification cards, contracts or personnel action forms, employment record, education certificates, diplomas, pay vouchers, certificates or awards,
casualty information, and any other supporting evidence of membership and character of service performed.
4. The appropriate service will not provide counsel representation for applicant, nor will it defray cost of such counsel under any circumstances.
5. In the event the service decides information provided by the applicant is incomplete, the application will be returned without prejudicing later information.
MAIL COMPLETED APPLICATION TO THE APPROPRIATE ADDRESS BELOW:

ARMY:

US Army Resources Command
ATTN: AHRC-PDR-VIB
1600 Spearhead Division Avenue Dept 420
Fort Knox, KY 40122-5402

NAVY:

Navy Personnel Command
(PERS-312)
Millington, TN 38054-5045

MARINE CORPS:

Commandant of the Marine Corps (Code: MMSB-12)
2008 Elliot Road, Suite 222
Quantico, VA 22134-0001

AIR FORCE:

COAST GUARD:

DD FORM 2168, MAR 2021
PREVIOUS EDITION IS OBSOLETE.

DRAFT
AFPC/DPSOS
550 C Street West, Suite 3
Randolph AFB, TX 78150-4713

United States Coast Guard
National Maritime Center (NMC)
100 Forbes Dr.
Martinsburg, WV 25401

CUI (when filled in)

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