(a) Period(s) of active duty (if same as above, write “same” ):      
               (b) Amount of wages for period(s) shown below:
               
                  
                     
                        
                        
                     
                     
                        
                        
                           
                           | Period | Amount (amount of basic pay) | 
                     
                     
                        
                        
                           
                           |  |  | 
                     
                  
                
               If the amount of wage is not available, please provide:
               (c) Indidivual's rank or pay grade during (this)(each) period and the date of rank:      
               (d) Number of years of service completed for pay purposes (longevity) for (this)
               (each)period):       
                
               
                  
                     
                        
                        
                     
                     
                        
                        
                           
                           | Date | Signature: | 
                        
                           
                           |  | Title: | 
                        
                           
                           |  | (State Adjutant General or Authorized Representative) |