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  1. Authorization to Record/Request Copy of Military Discharge Document

  2. I, the undersigned, do hereby swear or affirm that I am the proper person within GS 47-113.2(b) to authorize _______________________________, serving as authorized agent or representative, to (record) (request a copy of) the military discharge document for ___________________________ (veteran's name). I hereby request that the Register of Deeds (record) (issue an uncertified copy of) (issue certified copy of) the military discharge document for the above named veteran for/to the bearer of this authorization.

  3. This ___ day of __________, 20____.

  4. __________________________________________________________

  5. (Signature of Veteran, veteran's widow/widower, power of attorney, or veteran's executor)

  6. Subscribed and Sworn to before me this _____________ day of ________________, 20_____

  7. ______________________________________________Notary Public

  8. My Commission expires: ________________________________

  9. SEAL

  10. Leave This Blank: