Verification Of Birth

REQUEST FOR VERIFICATION OF BIRTH Ffc'e9dtill9hlrdenfrthis@||ectionofinformationisest.matedtoaverage5minutesperrespon*,iocludin9thetimeforrviewin9instrctions, Eng ad mtrk*ng ttle data Rded, and ompleting and Gviewing the collstion of iofomation. Send comments regarding this burden stimte or aoy other aspst of this collection of rEtir, ircbda.lg sggstions for rcducing the burden, to the Department of Defense, Extutive Serics and Communi@tions DirectoGte MO4_0006). RespondenG should be awaG that any other prcvision of law, no peFon shall be subject to any penalty for failing to comply with a collection of information if it does not disDlay a cutrently valid OMB @ntrol

DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE ADDRESS

II{ SECTION III, ITEM 14.b.

(Fillin every item in this section) 2. R LL NAME OF CHILD AT TIME OF BIRTH (tast, First,

sEx (x) MALE

4'

DATE OF BIRTH (YYYYMMDD)

FEMALE PLACE OF BIRTH

10.

RECRUMNG OFNCER/REPRESEI{TATIVE MAKING

a. NAME (Last, First, Middle Initial)

sEcrD{fl (For use

by Vital Statistis Department only)

E. STATE

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. 12. VERIFIED BY (Signature)

srnt(For

e-

completion by recruiting office)

RFCRUITER

SIGNAruRE

d. DATE SIGNED

f.

ZIP CODE

11, FILE DATE