MILITARY ADMINISTRATIVE SEPARATION RESPONSE

PROCEDURE TYPE

☐ Notification Procedure (Less than 6 years of service or Honorable/General discharge proposed)
☐ Board Procedure (6+ years of service OR OTH discharge proposed)

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SECTION I: SERVICE MEMBER INFORMATION

Full Name: [________________________________]

Rank/Grade: [________________________________]

Branch of Service: ☐ Army ☐ Navy ☐ Air Force ☐ Marine Corps ☐ Coast Guard ☐ Space Force

SSN (Last 4): [____]

Unit: [________________________________]

Duty Station: [________________________________]

Date of Entry on Active Duty: [__/__/____]

Total Active Federal Military Service: [____] Years [____] Months [____] Days

ETS/EAOS Date: [__/__/____]

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SECTION II: NOTIFICATION INFORMATION

Date Notification Received: [__/__/____]

Response Deadline: [__/__/____]

Initiating Commander: [________________________________]

Separation Authority: [________________________________]

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SECTION III: BASIS FOR PROPOSED SEPARATION

A. Reason for Separation

☐ Parenthood (DoDI 1332.14, Para 3.5)
☐ Dependency or Hardship (DoDI 1332.14, Para 3.6)
☐ Designated Physical or Mental Condition (DoDI 1332.14, Para 3.7)
☐ Defective Enlistment or Induction (DoDI 1332.14, Para 3.8)
☐ Entry Level Performance and Conduct (DoDI 1332.14, Para 3.9)
☐ Unsatisfactory Performance (DoDI 1332.14, Para 3.10)
☐ Minor Disciplinary Infractions (DoDI 1332.14, Para 3.11)
☐ Pattern of Misconduct (DoDI 1332.14, Para 3.12)
☐ Commission of a Serious Offense (DoDI 1332.14, Para 3.13)
☐ Drug Abuse (DoDI 1332.14, Para 3.14)
☐ Alcohol Rehabilitation Failure (DoDI 1332.14, Para 3.15)
☐ Homosexual Conduct (Pre-2011 cases only)
☐ Security (DoDI 1332.14, Para 3.17)
☐ Other: [________________________________]

B. Proposed Characterization of Service

☐ Honorable
☐ General (Under Honorable Conditions)
☐ Other Than Honorable (OTH)
☐ Entry Level Separation/Uncharacterized

C. Specific Allegations/Incidents

Date	Incident/Allegation	Documentation
[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]

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SECTION IV: SERVICE MEMBER'S RIGHTS

A. Acknowledged Rights

☐ I have received written notification of the proposed separation
☐ I have been informed of the basis for the proposed separation
☐ I have been informed of my right to consult with counsel
☐ I have been informed of the characterization of service being considered
☐ I have been informed of the potential consequences of separation

B. Counsel Consultation

☐ I have consulted with military defense counsel
☐ I have consulted with civilian defense counsel (at my own expense)
☐ I waive my right to consult with counsel

Military Defense Counsel: [________________________________]

Civilian Defense Counsel (if applicable): [________________________________]

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SECTION V: SERVICE MEMBER'S ELECTIONS

A. For Notification Procedure

☐ I DO NOT submit a statement in my behalf
☐ I submit the attached statement in my behalf
☐ I WAIVE my right to obtain copies of documents supporting the proposed separation
☐ I REQUEST copies of documents supporting the proposed separation

B. For Board Procedure (if eligible)

☐ I REQUEST an administrative separation board
☐ I WAIVE my right to an administrative separation board

If Requesting a Board:

☐ I request a personal appearance before the board
☐ I waive my right to a personal appearance (records review only)
☐ I request representation by military counsel
☐ I request to be represented by civilian counsel (at my own expense)
☐ I request that the board be open to the public
☐ I request that the board be closed to the public

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SECTION VI: RESPONSE TO ALLEGATIONS

A. Position on Allegations

☐ I deny the allegations in their entirety
☐ I admit the allegations but contest separation
☐ I admit some allegations and deny others (specify below)
☐ I do not contest the facts but dispute their characterization

B. Detailed Response

Regarding Allegation 1:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Regarding Allegation 2:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Regarding Allegation 3:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

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SECTION VII: MATTERS IN DEFENSE

A. Factual Defense

☐ The alleged conduct did not occur
☐ The conduct does not constitute a basis for separation
☐ Procedural errors occurred in processing this separation
☐ The evidence is insufficient to support separation
☐ Other: [________________________________]

Explanation:
[________________________________]
[________________________________]
[________________________________]

B. Supporting Evidence/Documentation

Exhibit	Description
[____]	[________________________________]
[____]	[________________________________]
[____]	[________________________________]

C. Witnesses

Name	Contact	Expected Testimony
[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]

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SECTION VIII: MATTERS IN EXTENUATION

(Circumstances surrounding the conduct that help explain the events)

☐ Unusual stress or circumstances at the time:
[________________________________]
[________________________________]

☐ Provocation or contributing factors:
[________________________________]
[________________________________]

☐ Isolated incident not reflective of overall character:
[________________________________]
[________________________________]

☐ Mental health condition affected conduct:
[________________________________]
[________________________________]

☐ PTSD/TBI related to service:
[________________________________]
[________________________________]

☐ Other extenuating circumstances:
[________________________________]
[________________________________]

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SECTION IX: MATTERS IN MITIGATION

A. Military Service Record

Total Time in Service: [________________________________]

Combat Deployments:

Location	Dates	Notes
[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]

Non-Combat Deployments:

Location	Dates	Notes
[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]

Awards and Decorations:
☐ [________________________________]
☐ [________________________________]
☐ [________________________________]
☐ [________________________________]

Performance Evaluations Summary:
[________________________________]
[________________________________]

Special Qualifications/Schools:
[________________________________]

Prior Disciplinary Record:
☐ No prior disciplinary actions
☐ Prior actions (explain why this matter should still result in retention):
[________________________________]
[________________________________]

B. Personal Circumstances

Family Status:
☐ Single ☐ Married ☐ Divorced/Separated

Dependents:

Name	Relationship	Age
[________________________________]	[________________________________]	[____]
[________________________________]	[________________________________]	[____]

Financial Obligations:
[________________________________]
[________________________________]

Educational Background:
[________________________________]

Career Goals and Investment:
[________________________________]
[________________________________]

C. Medical/Mental Health Considerations

☐ PTSD diagnosis: [________________________________]
☐ TBI diagnosis: [________________________________]
☐ Other mental health condition: [________________________________]
☐ Physical condition: [________________________________]
☐ Currently in treatment: [________________________________]

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SECTION X: REHABILITATION POTENTIAL

A. Steps Already Taken

☐ Completed counseling/treatment program
☐ Addressed underlying issues
☐ Demonstrated improved performance
☐ No further incidents since: [__/__/____]
☐ Other corrective actions:
[________________________________]
[________________________________]

B. Future Commitments

☐ Willing to participate in rehabilitation program
☐ Willing to accept rehabilitative transfer
☐ Committed to specific corrective actions:
[________________________________]
[________________________________]

C. Evidence of Rehabilitation

Document	Description
[____]	[________________________________]
[____]	[________________________________]

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SECTION XI: CHARACTER EVIDENCE

A. Letters of Support

Name	Rank/Position	Relationship	Exhibit
[________________________________]	[________________________________]	[________________________________]	[____]
[________________________________]	[________________________________]	[________________________________]	[____]
[________________________________]	[________________________________]	[________________________________]	[____]

B. Character Witnesses (for Board Hearing)

Name	Rank/Position	Contact	Will Testify To
[________________________________]	[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]	[________________________________]

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SECTION XII: REQUEST FOR RELIEF

A. Primary Request

☐ Retention in the military
☐ Separation with Honorable characterization
☐ Separation with General (Under Honorable Conditions) characterization
☐ Suspended separation
☐ Rehabilitative transfer
☐ Other: [________________________________]

B. Alternative Requests (in order of preference)

1. [________________________________]
2. [________________________________]
3. [________________________________]

C. Narrative Reason Request

If separation is approved, I request the narrative reason be:
[________________________________]

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SECTION XIII: IMPACT OF SEPARATION

A. Benefits at Risk

☐ GI Bill education benefits
☐ VA healthcare eligibility
☐ VA disability compensation eligibility
☐ Veterans' preference for federal employment
☐ State veterans' benefits
☐ Military retirement eligibility (if applicable)
☐ Other: [________________________________]

B. Personal Impact

[________________________________]
[________________________________]
[________________________________]

C. Family Impact

[________________________________]
[________________________________]
[________________________________]

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SECTION XIV: LEGAL ARGUMENT

A. Procedural Issues

☐ Notification was not timely served
☐ Notification was deficient in content
☐ Required endorsements/recommendations missing
☐ Investigation was inadequate
☐ Other procedural defects: [________________________________]

B. Substantive Issues

☐ Insufficient evidence to support basis for separation
☐ Conduct does not meet regulatory criteria
☐ Characterization proposed is too severe
☐ Mitigating factors warrant retention
☐ Separation would be inequitable
☐ Other: [________________________________]

C. Detailed Legal Argument

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

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SECTION XV: CERTIFICATION AND SIGNATURE

I, [________________________________], certify that:

1. I have read and understand the notification of proposed separation
2. I have been advised of my rights
3. I have had the opportunity to consult with counsel
4. The statements in this response are true to the best of my knowledge
5. I make my elections knowingly and voluntarily

Service Member Signature: [________________________________]

Date: [__/__/____]

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SECTION XVI: COUNSEL CERTIFICATION

I certify that I have advised [________________________________] of their rights under applicable regulations and have assisted in preparing this response.

Counsel Signature: [________________________________]

Printed Name: [________________________________]

Rank/Title: [________________________________]

Date: [__/__/____]

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EXHIBITS CHECKLIST

☐ Exhibit A: Character reference letters
☐ Exhibit B: Performance evaluations
☐ Exhibit C: Awards documentation
☐ Exhibit D: Training certificates
☐ Exhibit E: Medical/mental health records
☐ Exhibit F: Treatment completion certificates
☐ Exhibit G: Witness statements
☐ Exhibit H: Other supporting documents: [________________________________]

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POST-SEPARATION APPEAL OPTIONS

If separated, you may have the following appeal options:

1. Discharge Review Board (DRB) - Within 15 years of discharge
2. Board for Correction of Military Records (BCMR) - Within 3 years of discovering error/injustice
3. Discharge Appeal Review Board (DARB) - Document review of DRB decision

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SOURCES AND REFERENCES

• DoDI 1332.14 - Enlisted Administrative Separations
• DoDI 1332.30 - Commissioned Officer Administrative Separations
• GAO Report on Administrative Separation Boards
• Military.com - Basics of Administrative Separation

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This template is provided for educational and informational purposes. Administrative separations have serious, lifelong consequences. Always consult immediately with a qualified military defense attorney when facing separation.