Dd Form 2168 PDF Details

For individuals or survivors seeking recognition of a group's active duty service with the United States Armed Forces, the DD 2168 form serves as a critical application tool. This document facilitates the submission process for obtaining an appropriate certificate of service, necessary for accessing various benefits. The form is governed by Public Law 95-202, Sec. 401, Executive Order 9397, and its completion is estimated to take about 30 minutes. Notably, providing personal identifiers, such as a Social Security Number, is imperative to ensure accurate processing and identification. The form contains several sections that require detailed information about the service member’s personal data, group service data to support the claim, and specific application information. It underscores the importance of submitting comprehensive evidence, from separation discharge certificates to mission orders and employment records, to support the application. Additionally, it outlines the routing uses of the submitted information, illustrating how it can be leveraged to substantiate benefit eligibility and support claims across government departments. Completion and submission instructions are explicit, emphasizing the necessity of original copies and warning against the submission to the Department of Defense but rather to the designated service addresses. This proactive approach is designed to streamline the application process, ensuring that claims are handled efficiently and accurately.

QuestionAnswer
Form NameDd Form 2168
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdd 2168 updated, dd form 2168, va form 2168, form dd 2168

Form Preview Example

APPLICATION FOR DISCHARGE OF MEMBER OR SURVIVOR OF MEMBER

OMB No. 0704-0100

OF GROUP CERTIFIED TO HAVE PERFORMED ACTIVE DUTY

 

WITH THE ARMED FORCES OF THE UNITED STATES

OMB approval expires

 

(Read Instructions on back before completing form.)

Jun 30, 2011

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 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, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0100). 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, Sec. 401, and EO 9397.

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 Veterans Affairs to provide substantiation for benefit eligibility. To the Department of Justice in pending or potential litigation to which the record is pertinent.

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

b. ALIAS(ES)

 

2. SSN

 

 

3. DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

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

b. CITY

 

c. COUNTY

 

d. STATE

 

e. ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

II. SERVICE GROUP DATA TO SUPPORT CLAIM

 

 

 

 

 

 

 

 

 

5. NAME OF GROUP SERVED WITH

6. IDENTIFICATION NO.

7. HIGHEST GRADE/RANK/RATING HELD

8. HIGHEST PAY GRADE

 

 

 

 

 

 

 

 

 

(or actual pay)

 

 

 

 

 

 

 

 

9. ENTRY INTO SERVICE

 

 

 

 

10. ACTUAL MILITARY SERVICE BEFORE/AFTER THIS SERVICE

a. DATE (YYYYMMDD)

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

 

a. DATES (YYYYMMDD)

b. DEPARTMENT(S)

 

 

 

 

 

 

 

 

 

11. HOME OF RECORD AT TIME OF ENTRY

 

 

 

 

 

 

12. GRADE/RANK/RATING

 

 

 

 

 

 

 

AT TIME OF ENTRY

a. STREET ADDRESS (Incl. apartment number)

b. CITY

 

c. COUNTY

d. STATE

e. ZIP CODE

 

 

 

 

 

 

 

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

14. SPECIALTY JOB TITLE(S)

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

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

a. TYPE OF

b. REASON

c. STATION BASE/LOCATION

d. SERVICE COMMAND

e. DATE SERVICE

TERMINATION

 

 

AFFILIATION

TERMINATED (YYYYMMDD)

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

 

c. WIDOWER

 

e. LEGAL REPRESENTATIVE

 

b. WIDOW

 

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

a.NAME (Last, First, Middle)

b. SSN

c. SIGNATURE

d.DATE SIGNED

(YYYYMMDD)

e. MAILING STREET ADDRESS (Incl. apartment number)

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

a. SIGNATURE

 

b. DATE SIGNED

maintained by the National Personnel Records Center to the

 

 

 

(YYYYMMDD)

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, APR 2010 (CORRECTED)

PREVIOUS

EDITION IS OBSOLETE.

 

Adobe Professional X

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:

AFPC/DPSOS

 

550 C Street West, Suite 3

 

Randolph AFB, TX 78150-4713

COAST GUARD:

United States Coast Guard

 

National Maritime Center (NMC)

 

100 Forbes Dr.

 

Martinsburg, WV 25401

DD FORM 2168 (BACK), APR 2010 (CORRECTED)

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2. Immediately after the last part is completed, go to type in the applicable details in these - III APPLICATION INFORMATION, a SPOUSE b WIDOW, RELATIONSHIP TO APPLICANT X one I, e LEGAL REPRESENTATIVE f OTHER, c WIDOWER d NEXT OF KIN, c SIGNATURE, b SSN, d DATE SIGNED YYYYMMDD, e MAILING STREET ADDRESS Incl, CITY, STATE, ZIP CODE, f TELEPHONE Include area code, IV DISCLOSURE OF INFORMATION I, and a SIGNATURE.

c SIGNATURE, STATE, and RELATIONSHIP TO APPLICANT X one I inside va form 2168

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