MTF LETTERHEAD
Office Symbol
(Date)
SUBJECT:
Request for Statement of Service for
Physical Disability Action
Department of the Army
Commander
Personnel Command
U.S. Army Enlisted Records and
ATTN: DAPC-POS-RD
Evaluation Center
200 Stovall Street
ATTN: PCRE-RC
Alexandria, VA 22332
Ft. Benjamin Harrison, IN 46249
OR
Commander
Appropriate State Adjutant General
U.S. Army Reserve Components
Personnel and Administration
Center
9700 Page Boulevard
St. Louis, MO 63132
1. Name
, RANK
, SSN
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:
(Signature)
Figure 5-5. Request for statement of service.
MD0755
5-25