I appoint
(Print/Type
Name and Address of Representative) to act as my representative
in connection with my appeal under
32 CFR 199.10,
Appeal and Hearing Procedures. To avoid the possibility of a conflict
of interest, I understand that an officer or employee of the United
States (US), to include an employee or member of a Uniformed Service,
an employee of a Uniformed Service legal office, a Market/Military
Medical Treatment Facility (MTF) provider or a Beneficiary Counseling
and Assistance Coordinator (BCAC), is not eligible to serve as a representative.
An exception to this is made when an employee of the US or member
of a Uniformed Service is representing an immediate family member.