Military Discharge Copy Request Form

LaSalle County Recorder of Deeds 707 E. Etna Road, Suite 269 Ottawa, IL 61350 (815) 434-8226 Military Discharge Copy Request Form Date: ________________________ Name of Veteran: (Please Print)__________________________________ Name of person requesting copy of discharge: (Please Print) ________________ Relationship to Veteran: (Please Print) _______________________ Signature: ________________________________ NOTARY SECTION: STATE OF _______________________ COUNTY OF _____________________ I, the undersigned, a Notary Public in and for said County, in the State aforesaid, DO HEREBY CERTIFY THAT ____________________________________________, personally known to me to be the same person whose name if subscribed to the foregoing instrument appeared before me this day in person and acknowledges that _______________________ (he/she) signed, sealed and delivered the said instrument as (his/her) ____________________ free and voluntary act. Signature _______________________________ Given under my hand and notarial seal, this ____ day of ________________ 20___. __________________________ Notary Public My commission expires___________, 20 ____ IMPRESS SEAL HERE American LegalNet, Inc. www.FormsWorkFlow.com