Request for Pro Bono Assistance for Discharge Review and Correction

Hello Veteran,

Public Counsel and its Center for Veterans' Advancement is a legal aid organization and we provide military veterans assistance to request a review of their active-duty discharge by the applicable Board of Correction or Review Board. Public Counsel does not charge fees for its services and services are in pro per (you are representing yourself).

By completing the below questions, you understand that unless you sign a separate Retainer Agreement, Public Counsel Law Center and the Center for Veterans' Advancement, will have no responsibility for your case and will not represent you. You also understand that completing this form does not guarantee that you will receive legal services, additional income-eligibility requirements apply, and that you are responsible for meeting any initial deadlines that may apply to your case.

Please allow at least 15 minutes to review and complete the below questions completely and truthfully about yourself and your military experiences. All information will be kept confidential and used for assessment and placement purposes only. After you submit this form, we will contact you within two weeks.

For questions about this form or for assistance completing it, please contact the Center for Veterans' Advancement at cva@publiccounsel.org or call 213-385-2977, ext 304.

For agency provider referrals, please enter the name of your agency.

Dole Foundation/Hidden Heroes Foundation Salvation Army VA Other

If you were referred by the Salvation Army, please provide your case worker's name:

Are you or someone in your household a caregiver to a veteran?

Yes No

Name *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Email

example@example.com

Date of Birth

Date

Gender Identity

Ethnicity

Asian/Pacific Islander Black Hispanic Native American Caucasian/White

Total HOUSEHOLD Gross (before tax) income and benefits per a month *

	Amount
Wages/Employment
CALWORKs
CALFRESH
General relief
Social Security Disability
Social Security Retirement
Supplemental Security Income (SSI)
VA Pension
VA Service-Connected Benefits
Other income

Household size (including yourself): *

Branch of military *

Army Coast Guard Air Force Navy Marine Corps National Guard

Character of Discharge *

Honorable General/Under Honorable Other Than Honorable (OTH) Bad Conduct Dishonorbale

Date Entered the Military *

Date

Date Discharged from the Military *

Date

What do you want corrected on your DD-214 (narrative reason, comments, remarks, character of discharge, separation authority, etc.)? *

Was there anything that affected your capability to adjust to the military or to serve? (e.g., youth, young age, maturity, learning disability, family, personal problems, military arbitrary actions, discrimination). If yes, please explain?

Was there anything that happened to you that harmed you or had a lasting negative impact? (e.g., were you harassed or assaulted? Was the assault sexual in nature?). If yes, explain further.

Did you receive any physical injuries while in the military? If yes, please explain when, how and where did they happen?

Did the injuries affect your performance, treatment by others, actions or behaviors in the military? If yes, please explain.

Did you experience mental health condition(s) while in the service (such as PTSD, TBI, anxiety, depression, etc.)? If yes please explain further: Was the condition(s)diagnosed or treated while in the military? What impact or effect did these conditions have on you? (Include any behavioral, psychological, social, or physical impacts).

Describe the events or circumstances that led up to your discharge. If applicable, include level of Court Martial, NJP's, Art 15s, UA/AWOL, drug use etc.

If applicable, were you offered rehabilitation, counseling, or classes to overcome any alleged deficiencies in performance, or otherwise offered a second chance?

Are there additional reasons that you believe your discharge was in error, was unfair or unjust (comparing the positive aspects of conduct or performance; awards, commendations, combat/hazard duty, wounds/injuries, promotions, higher-level responsibilities, length of service, acts of merit, multiple enlistment periods, no other misconduct, etc.)?

Are you VA Service-Connected for any conditions? If so, what conditions and at what rating (%). *

Have you received post-service treatment (mental/ physical therapy, counseling, groups, etc.) for military-related health conditions? If so, when, and for how long?

What were your experiences like as you transitioned to a civilian? (positive or negative)

What are some of the post-service accomplishments you have had? (e.g., mentoring, community work, volunteering, faith-based groups, education, sobriety, family life, employments and promotions, etc.)

What are the primarily motivating reasons for you to receive assistance for a correction of your military discharge? *

Thank you for your time and thorough responses. For more effective services, we recommend acquiring the additional following supporting information, such as:

" DD-214 and military service records (personnel file and service treatment records) available via the National Personnel Records Center (https://www.archives.gov)

" Medical records regarding disabilities that may be service-connected or related to discharge;

" Letters of support or character references from fellow service-members, family, or friends (who knew you during your service or know your well);

" Certificates of positive post-service conduct, including educational, community service, or rehabilitation and treatment achievements;

" Any other relevant documents relating to mitigation and circumstances of your discharge.

We will retain this information for the purpose of intake, assessment, pro bono (volunteer attorney) placement, or to schedule you for a discharge upgrade clinic.

Request for Pro Bono Assistance for Discharge Review and Correction

Identifying Information