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MILITARY DISCHARGE CERTIFICATE RELEASE FORM DATE: I, swear, depose, and state upon my oath, that I am entitled to disclosure of the Military Discharge Certificate of (Name of the Service Member of the United States Military) recorded in the office of the Big Horn County Clerk and Recorder, in Book Page on (date). Approximate Year of Military Separation Date: FURTHER, that pursuant to Montana law, I qualify to obtain information from, or obtain a copy of the Military Discharge Certificate as: (Please check one) The service member who filed the certificate. The next of kin of the service member (if the service member is deceased). (FILL OUT THE ATTACHED AFFIDAVIT) A mortuary, as defined in §10-2-111, MCA, for the purpose of securing burial benefits. A Veteran’s Service Office or a Veterans’ Service Organization, as defined in §10-2-111, MCA. The Veteran’s Affairs Division of the Montana Department of Military Affairs. A person with written authorization (notarized) from the service member or from the next of kin, if the service member is deceased. Signature of Applicant Street or Post Office Address City State Zip Code This instrument was acknowledged before me on this day of by (SEAL) Printed Name: Notary Public for the State of Montana. Residing at Montana. My Commission expires ---PAGE BREAK--- AFFIDAVIT I, hereby request a certified copy of the Military Discharge Certificate for a former service member of the United States Military. The service member listed is now deceased. WHEREAS, the Military Discharge Certificate has been removed from the definition of “public records” under §2-6-401, MCA, and WHEREAS, §7-4-2614, MCA, has been amended to limit the disclosure of a Military Discharge Certificate. I, do hereby swear that I understand that Military Discharge Certificates are confidential. I also swear that I am qualified to obtain a Military Discharge Certificate as I am the “Next of Kin” of the service member. More specifically, I am the surviving spouse, a parent, or a descendant of the service member. My relationship t the service member is that of Signature of Applicant Printed Name of Applicant STATE OF MONTANA ) ) ss COUNTY OF ) On this day of before me, a Notary Public for the State of Montana, personally appeared known or proved to me to the person who executed the within instrument. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year first above written. (SEAL) Printed Name: Notary Public for the State of Montana. Residing at Montana. My Commission expires: