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Affidavit to View or Copy Military Discharge Records Identifying Information of Person Desiring to View or Copy Records Name: Address: City: Zip Code: 1Driver’s License/Social Security Number: Identifying Information of Person Whose Military Discharge Records are on File in Clerk’s Office Name: Date of Birth: Social Security Number: Approximate Date of Discharge from Military Services: I, the party named in Section above, hereby certify to the Clerk of Richmond Superior Court, Augusta, Georgia, that I am (check appropriate box): The person who is the subject of the record The spouse or next of kin of the person who is the subject of the record A person named in an appropriate power of attorney executed by the person who is the subject of the record The administrator, executor, guardian, or legal representative of the person who is the subject of the record; or An attorney for any person specified in subparagraphs through of this paragraph. I understand the following, as provided in O.C.G.A. § 15-6-72 of the Official Code of Georgia Annotated: • Records I obtain pursuant to this request shall not be reproduced or used in whole or in part for any commercial or speculative purposes. • I am prohibited by law from disseminating or disclosing military discharge information or any part thereof except as authorized in O.C.G.A. § 15-6-72 or as otherwise provided by law. • Violation of this subsection shall constitute a misdemeanor and shall be punished by a fine not to exceed $5,000.00. • The clerk of the superior court shall not be liable and shall be held harmless should I copy, reproduce, or use records I view or receive copies of in violation of O.C.G.A. § 15-6-72. Under the penalty of law, I, the person named in Section above, certify that the above and foregoing information is true and correct. Signature of Person Making this Request 1 Required information that must be verified by Clerk or Deputy Clerk.