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Signature of Alloter ADMINISTRATIVE ACTION For Payroll Use Only Processed Verified PHS-6173 Rev. 3/05 FRONT PSC Media Arts 301 443-1090 EF Application for Allotment of Pay -- PHS-6173 Privacy Act Notification Statement General The following information about this form and its uses is provided to you as required by the Privacy Act of 1974 5 U.S.C. 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 9. Purpose 8. Work Phone Number 10. Account Number if applicable Insurance Charity Dependent Support 11. Allotment Recipient 12. Check One Box Initial Authorization Amount Name Increase Allotment To From Cancel Authorization City 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. 552a. The form is part of the following system of records 09-40-0010 Pay Leave and Attendance Records HHS/PSC/HRS and 09-40-0001 PHS Commissioned Corps General Personnel Records HHS/PSC/HRS* Authority for Collection of Information Title 37 U*S* Code Section 704 P. L* 87-649 Revision and Codification of Title 37 -- Pay and Allowances of Uniformed Services and Executive Order 9397. Principal Purpose and Routine Uses The information you are requested to supply on this form will be used to process your allotment of pay to a financial organization or other designee. The information may also be used under exceptional circumstances for other purposes including but not limited to the following 1. To respond to court orders for garnishment of an employee s pay for alimony or child support. for Federal income tax purposes. 3. To respond to Federal State or local agencies investigating or prosecuting a violation of law. Effects of Nondisclosure Disclosure of your Social Security Account Number SSAN is mandatory. The SSAN is requested for identification purposes. Failure to supply complete and accurate information may result in delays and/or denial of request. 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. Name Last First Middle 2. Date 3. Social Security Number Type or Print 4. Address 5. City 6. State 7. Zip Code 9. Purpose 8. Work Phone Number 10. Account Number if applicable Insurance Charity Dependent Support 11. .

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