Phs-6173 - Application For Allotment Of Pay - Commissioned Corps Management

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
For Payroll Use Only
APPLICATION FOR ALLOTMENT OF PAY
Please read Privacy Act Statement on back
before completing this form
Deliver to: Office of Commissioned Corps Support Services
ATTN: Compensation Branch
5600 Fishers Lane, Room 4-50
Rockville, MD 20857-0001
1. Name (Last, First, Middle)
2. Date
3. Social Security Number
(Type or Print)
4. Address
5. City
6. State
7. Zip Code
8. Work Phone Number
9. Purpose
10. Account Number (if applicable)
Insurance
Charity
Dependent Support
11. Allotment Recipient
12. Check One Box
Initial Authorization Amount
Name
Increase Allotment
From
To
Address
Decrease Allotment
From
To
Cancel Authorization
City
State
Zip
13. Effective Date For Action
14. Request and Authorization
I hereby request and authorize the above pay allotment to be initiated
and to remain in effect until revoked by me in writing.
Signature of Alloter
ADMINISTRATIVE ACTION (For Payroll Use Only)
Processed:
Verified:
PHS-6173
FRONT
EF
PSC Media Arts (301) 443-1090
(Rev. 3/05)

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