Author: Lance Mendoza
Last saved by: Patrick Stewart

Dated: ___________________ 

[Name: First Middle Last]
c/o Address 
City, State Postal Code

Branch address found on
Second page of DD 2168 

To (Branch of Military): 
It is my wish and intention that I shall be recognized now and forevermore as fully, completely, and permanently discharged from U.S. military service and severed from the accompanying obligations of federal citizenship. 
I have returned to my natural birthright political status and removed my permanent domicile to the land and soil of my birth state. 
Please confirm my election to be removed from any further claim of federal connection effective with my date of discharge as shown on the DD 214/NGB 22 associated with my name. 
Sincerely yours, 

By:__________________________________________ © 
Name ©, All Rights Reserved