1) I __________________ have been counseled in accordance with AR 635-8 Chapter 6 and Army Directive 2021-05 para (3) (d) pertaining to my election of a separation date due to being medically separated from the Army. (________) Soldier's initials.
2) I understand that a Department of Veteran Affairs (DVA) service connected disability incurred in or aggravated by military service may be established from the day following my date of separation from the Army. By law, entitlement to payments is not authorized until the first of the month following the month in which the service connection is established. DVA compensation is pay, like military pay, in arrears. Because of this, I understand there will be a delay in receipt of DVA payments and I will plan accordingly. (_______) Soldier's initials.
3) I understand that, should I elect to be separated prior to the 20th of the month, this decision could result in overpayment by the Army which would create a debt that I will be responsible to repay. (_______) Soldier's initials.
4) I understand that should I elect to be separated on the last day of the month, this decision will result in the loss of one month of veteran's disability benefits and payments. (______) Soldier's initials.
5) I request to be separated on: __________________________ .
__________________________________
COMMANDER'S PRINTED NAME
__________________________________
COMMANDER'S SIGNATURE
__________________________________
SOLDIER'S PRINTED NAME
__________________________________
SOLDIER'S SIGNATURE
__________________________________
DATE SIGNED
