Get Phs-6363 2004-2024

A change of address/transfer will not affect your current direct deposit. If you wish to designate a new financial institution for your monthly salary you must complete a new SF-1199A Direct Deposit Sign-Up Form. SIGNATURE Must be signed not printed or stamped DATE Return this form to Office of Commissioned Corps Support Services ATTN Compensation Branch 5600 Fishers Lane Room 4-50 Rockville MD 20857-0001 PHS-6363 Rev. 12/04 PSC Media Arts 301 443-1090 EF PHS-6363 PRIVACY ACT STATEMENT This statement is provided pursuant to the Privacy Act of 1974 5 U.S.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Commissioned Corps REQUEST TO ESTABLISH / CHANGE MAILING ADDRESS NAME Please print or type SOCIAL SECURITY NUMBER MY STATUS IS ACTIVE Please check applicable box RETIRED MY WORK PHONE NUMBER IS ANNUITANT I am requesting that you establish/change my mailing address to read as follows LIMIT - 30 CHARACTERS PER LINE Street Address Line 1 City State ZIP Code NOTE Your salary must be directly deposited to a financial institution of your choice. 552a. Our authority to collect this information is 37 U*S*C. 403 42 U*S*C. 202 et seq. and Executive Order 9397 Numbering System for Federal Accounts Relating to Individual Persons. The information provided on this form will become part of record systems 09-40-0001 PHS Commissioned Corps General Personnel Records HHS/PSC/HRS and 09-40-0010 Pay Leave and Attendance Records HHS/PSC/HRS* officers or annuitants. This information will be used only as necessary in personnel and pay administration processes carried out in accordance with established regulations and published notices of systems of records. Copies of these systems of records may be obtained by contacting the office to which you submit this form* Information Regarding Disclosure of Your Social Security Number SSN Disclosure of the SSN is mandatory under provisions of the Social Security Act since Public Health Service Commissioned Corps officers are under Social Security covered employment and taxes must be withheld from their salaries. The SSN is also used as an identifier throughout an officer s career. It is used primarily to identify an officer s personnel leave and pay records and to relate one to the other. The SSN is also used in connection with lawful requests for information from former employers educational institutions and financial or other organizations. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of the systems of records. The use of the SSN is made necessary because of the large number of present and former active inactive and retired officers and applicants who have identical names and birth dates and whose identities can only be distinguished by the SSN* PHS-6363 Back Rev* 12/04. 552a. Our authority to collect this information is 37 U*S*C. 403 42 U*S*C. 202 et seq. and Executive Order 9397 Numbering System for Federal Accounts Relating to Individual Persons. The information provided on this form will become part of record systems 09-40-0001 PHS Commissioned Corps General Personnel Records HHS/PSC/HRS and 09-40-0010 Pay Leave and Attendance Records HHS/PSC/HRS* officers or annuitants. .