Form Phs-7039 - Application For Allotment Of Pay printable pdf download

Form Phs-7039 - Application For Allotment Of Pay

For Payroll Use Only

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service Commissioned Corps

Division of Commissioned Personnel

APPLICATION FOR ALLOTMENT OF PAY

(For Additional Montgomery G.I. Bill Benefits)

Please read Privacy Act Statement on back

before completing this form.

Deliver to: Division of Commissioned Personnel

ATTN: Veterans Education Assistance

5600 Fishers Lane, Room 4-20

Rockville, MD 20857-0001

1. NAME (Last, First, Middle)

2. DATE

3. SOCIAL SECURITY NUMBER

4. ADDRESS

5. CITY

6. STATE

7. ZIP CODE

8. WORK PHONE NUMBER (Include

Area Code)

9. CHECK ONE BOX

Lump Sum Payment of $600. Personal check is attached and made out to the Department of Health

and Human Services. No deduction from pay will be made.

Lump sum Payment of $____________ and deduct $__________ from pay for _____ months to =

$600. Personal check is attached and made out to the Department of Health and Human Services.

Deduction must be a multiple of $4 and a minimum of $24.

Deduct $__________ per month for _____ months (must equal $600).

Deduction must be a multiple of $4 and a minimum of $24.

10. REQUEST AND AUTHORIZATION

I hereby request and authorize the above pay allotment to be initiated.

SIGNATURE OF ALLOTTER

DATE

ADMINISTRATIVE ACTION (For DCP Use Only)

OSB Clearance

Processed

Verified

PHS-7039 (3/02)

FRONT

Form Phs-7039 - Application For Allotment Of Pay