AUTHORIZATION TO START, STOP OR CHANGE AN ALLOTMENT
PRIVACY ACT STATEMENT
AUTHORITY: 37 U.S.C. Section 701, E.O. 9397.
PRINCIPAL PURPOSE: To permit starts, changes, or stops to allotments. To maintain a record of allotments and ensure starts, changes, and
stops are in keeping with member's desires.
ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act, these records of
information contained therein may specifically be disclosed outside the DoD as a routine use to the Federal Reserve banks to distribute payments
made through the direct deposit system to financial organizations or their processing agents authorized by individuals to receive and deposit
payments in their accounts. It may also be disclosed to the Treasury Department, Internal Revenue Service, Social Security Administration,
Department of Veterans Affairs, Federal, state and local agencies for civil or criminal law enforcement. In addition it can be released for any of the
blanket routine uses published at the beginning of the DFAS compilation of system of record notices.
DISCLOSURE: Voluntary; however, failure to provide the requested information as well as the Social Security number may result in the member
not being able to start, change, or stop allotments.
TO BE COMPLETED BY ALLOTTER
2. NAME OF ALLOTTER (Last, First, Middle Initial)
4. PAY GRADE
1. BRANCH OF SERVICE (X one)
(Print or type)
5. ADDRESS OF ALLOTTER (Street or Box Number, City, State,
6. DAYTIME TELEPHONE
8. MONTHLY AMOUNT
NUMBER (Include Area
9. NAME OF ALLOTTEE (First, Middle Initial, Last)
11. TERM IN MONTHS
10. ALLOTMENT ACTION
NGASD INSURANCE PROGRAM
12. CREDIT LINE (If applicable)
13. ALLOTMENT CLASS AUTHORIZED (X one)
C - CHARITY/CFC
D - DISCRETIONARY ALLOTMENTS (Includes dependent support, payment
14. ALLOTTEE'S MAILING ADDRESS (Street or Box Number,
to financial institution, insurance, repayment of home loan, rent, etc.
City, State, ZIP Code)
(Notes 1 and 2))
PO BOX 9089
F - CHARITY - EMERGENCY/ASSISTANCE FUND CONTRIBUTION
RAPID CITY, SD 57709-9089
L - REPAYMENT OF LOAN TO SERVICE ORGANIZATION (Red Cross, Relief
Society, etc. - Navy and Marine Corps only)
15. IF FOREIGN ADDRESS COMPLETE AS FOLLOWS (Province,
N - NSLI OR USGLI INSURANCE PREMIUM
T - PAYMENT OF DEBTS TO U.S., DELINQUENT STATE OR LOCAL INCOME/
- OTHER (Specify)
17. COMPANY CODE/FINANCIAL INSTITUTION/ROUTING
18. ACCOUNT NUMBER/POLICY NUMBER
19. TOTAL CLASS L AMOUNT
20. TOTAL CLASS T AMOUNT
STATEMENT OF UNDERSTANDING
I understand that this allotment is legal and that by voluntarily completing this form, I am responsible for:
- Ensuring that the information is correct;
- Reviewing my Leave and Earnings Statement to ensure the allotment stops, starts, or changes as directed including amount and payee;
- Collecting overpayments from the receiver (payee) of the allotment, if I do not change or stop the allotment after a loan is repaid;
- Contacting the receiver (payee) of the allotment, at my expense, to obtain monthly statements for my personal records.
I also understand that any problems once the allotment is delivered to the receiver (payee) are beyond the control of the Defense Finance and
Accounting Service (DFAS) and that DFAS is only responsible for ensuring proper delivery of any voluntary allotment for the period directed.
I further understand that pursuant to conditions listed in the DoD 7000.14-R, Volume 7A, changes can be made by DFAS to an allottee's
name, address, or account number.
21. SIGNATURE OF ALLOTTER
22. DATE (YYYYMMDD)
NOTE 1. Must be different address than allotter. Each dependent allotment must have a different credit line. Only one support allotment per
dependent is allowed.
NOTE 2. This is a voluntary allotment and can be to any payee you desire.
DD FORM 2558, SEP 2002
PREVIOUS EDITION IS OBSOLETE.
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