I hereby assign Carter L. Wilson III, acting for Family Research Group of Boise, Idaho, as my personal representative for the purposes of obtaining the Military Service Record, Pension File, and/or Medical Records of the veteran named below, including the Report of Separation (DD Form 214) and to obtain, copy, secure, or procure any and all documents, records or files to which I may be entitled under Federal, State, or other rules, regulation, or statute, pertaining to the veteran named below:
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Print Full Name of Veteran
I certify that I am the veteran named above or their surviving next of kin and my relationship to the veteran named above is (check one):
[ ] I am the veteran named above
[ ] Surviving Spouse that has not remarried
[ ] Father
[ ] Mother
[ ] Son
[ ] Daughter
[ ] Sister
[ ] Brother
This authorization is solely for the purposes named above and will automatically expire one (1) year from the date of my signature below. Where my signature or other written authorization is required to release a document, I authorize my representative named above, to sign on my behalf. A notarized copy of this document is considered as binding as the original document.
I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information that I provided is true and correct.
Signed this _____ day of _____________ 20___.
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Your Signature
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Please Print or Type Your Name
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Please Print or Type Your Mailing Address