Request for Statement of Service for
Physical Disability Action
Department of the Army
U.S. Army Enlisted Records and
200 Stovall Street
Alexandria, VA 22332
Ft. Benjamin Harrison, IN 46249
Appropriate State Adjutant General
U.S. Army Reserve Components
Personnel and Administration
9700 Page Boulevard
St. Louis, MO 63132
is being medically evaluated. He will probably be referred to a Physical Evaluation Board
in the near future.
2. Before final disposition can be made by HQDA, an official statement of service is
required. Please prepare a statement of service and forward it promptly to
HQDA(DAPC-EPA-D), 200 Stoval Street, Alexandria, VA 22332. The statement is
needed for issuing timely separation or retirement orders if the member is found unfit
because of physical disability.
FOR THE COMMANDER:
Figure 5-5. Request for statement of service.