(Use when PEB recommends separation without benefits)
U.S. Army Physical Evaluation Board
I have read the DA Form 199 (Physical Evaluation Board Proceedings) and your
letter explaining the rights of my (relation) regarding your findings and recommendations. I
understand that this action, if approved at Headquarters, Department of the Army, will result
in separation of my (relation) without compensation from the Army for his disability.
My decision regarding this action is shown in the appropriate box below.
/ / I agree with the finding and recommendation of the board and waive the right to
/ / I do not agree with the finding and recommendation of the board. A rebuttal
explaining my reasons is attached.
/ / I request until
to prepare and submit a rebuttal. I understand if my
rebuttal is not received by that date, the appointed counsel may submit a rebuttal in behalf
of my (relation) if he thinks it necessary.
Figure 5-15. Form letter for NOK (legal guardian) response to action of formal PEB
when separation without benefits is recommended.