Military Separation Pay Intake Form
Please complete all fields below to submit your military separation pay request for review.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Military Branch
*
Please Select
Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Other
Rank at Separation
*
Please Select
E-1 to E-4 (Junior Enlisted)
E-5 to E-9 (Senior Enlisted)
W-1 to W-5 (Warrant Officer)
O-1 to O-3 (Junior Officer)
O-4 to O-6 (Senior Officer)
O-7 and above (General/Flag Officer)
Other
Pay Grade at Separation
*
Please Select
E-1
E-2
E-3
E-4
E-5
E-6
E-7
E-8
E-9
W-1
W-2
W-3
W-4
W-5
O-1
O-2
O-3
O-4
O-5
O-6
O-7
O-8
O-9
O-10
Other
Date of Separation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Years of Service
*
Last Duty Station
*
Reason for Separation
*
Please Select
Normal Expiration of Service
Medical Separation
Retirement
Administrative Separation
Other
Upload Supporting Documents (e.g., DD214, discharge paperwork)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Request
Should be Empty: