Wis. Stats. Chapter 45	2135 Rimrock Road, P.O. Box 7843, Madison, WI 53707-7843 (608) 266-1311 | 1-800-WIS-VETS (947-8387)
REQUEST FOR RELEASE OF MILITARY SEPARATION RECORDS AND PERSONAL INFORMATION TO THE COUNTY OR TRIBAL VETERANS SERVICE OFFICE
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].
The provision of your social security number is voluntary. Failure to provide your social security number may result in an information processing delay.

Veteran’s Name:
Last	First	Middle
Date of Birth:	Social Security or Service Number:
I hereby authorize the Wisconsin Department of Veterans Affairs (WDVA) to discuss and release my/the veteran’s
military separation records, personal information, and application information to the
County or Tribal Veterans Service Office. (Note: This release is for all periods of service completed prior to the date this form is signed. If additional periods of service are completed after the submission of this form, or corrections are made to separation records after this form is signed, a new release will be required).
This authorization expires upon the death of the veteran. If signed by the veteran’s duly authorized representative, this authorization expires upon appointment of a new duly authorized representative. The authorizer can revoke this authorization by submitting a written request to WDVA.
I release WDVA, the VA, and the DOD for any liability regarding the release or discussion of such records to or with the County or Tribal Veterans Service Office I have authorized above. I acknowledge that any subsequent use or disclosure of such records by any entity which obtains such records cannot be controlled or prevented by WDVA, VA, or the DOD. This authorization to release and/or to discuss records is signed without solicitation or the expectation of any consideration. I understand that I may submit a written request to WDVA to revoke this authorization at any time except for information already released as a result of this authorization.
Authorization is being given by:
Veteran
Veteran’s Duly Authorized Representative* (Proof Required)
Signature of Veteran or Veteran’s Duly Authorized Representative*	Date
Address (Street, City, State, Zip Code)
Type of Photo ID	Photo ID Number
State of Issuance	Expiration Date

IDENTIFICATION REQUIREMENTS:

A photocopy of the authorizing individual’s current ID must be submitted with all mailed or faxed requests.

At least one form of ID must show your current name and current address. Expired cards or documents will not be accepted.

Acceptable forms of identification are:

One of these:

Wisconsin Driver’s License

Wisconsin Photo ID

Out-of-State Driver’s License or Photo ID Card

US Passport

OR

Two of these:

Check or Bank Book

Major Credit Card

Health Insurance Card

Recent Dated, Signed Lease

Recent Utility Bill or Traffic Ticket

*Veteran’s Duly Authorized Representative: “Duly authorized representative” means any person authorized in writing by the veteran to act for the veteran, the veteran’s guardian if the veteran is adjudicated incompetent, or a legal representative if the veteran is deceased. Where for proper reason no representative has been or will be appointed, the veteran’s spouse, an adult child, or, if the veteran is unmarried, either parent of the veteran shall be recognized as the duly authorized representative.

(Note: Consult your counsel with questions regarding acceptable written proof that an individual is the veteran’s duly authorized representative.)