Contribution Form - Active Duty Fund Drive printable pdf download

Contribution Form - Active Duty Fund Drive

| USMC Code: 954 USN Code: T602886

Contribution Form

DFAS INFO | USMC Code: 954 USN Code: T602886

secretary of the navy’s

active duty fund drive

First Name

_______________________

M.I.

______

Last

_____________________________

in support of the

Pay Grade

_________

SSN

____________________________________________

EDIPI

__________________________________________

_________________

(DFAS Requires SSN or EDIPI on Allotments Only)

Homeport / Station ___________________________________________________________________________

Help support Shipmates, fellow Marines and their families.

Command / UIC / RUC _______________________________________________________________________

Someday you may need them to return the favor.

EAOS / EAS (month / day / year) ______________________________________

Active Duty USMC

Retired USN*

Retired USMC*

Other

Active Duty USMC

Retired USN*

Retired USMC*

Other

Status

Active Duty USN

Active Duty USMC

Retired USN*

Retired USMC*

Other

Monthly Payroll Allotment

Other Ways to Give

*Forward copy 1 to NMCRS HQ

$10

$25

$35

check $ ____________

credit card $ __________________

$50

$100

other ___________

cash $ ______________

one-time charge

recurring/monthly charge

this 12-month allotment totals $

total check, cash or credit card contribution $

For allotments only: I hereby authorize the Department of the Navy to deduct the indicated amount from my pay each month for twelve (12) months starting June 1 and ending May 31 of the following year, pro-

vided that the amount deducted be remitted to the Navy-Marine Corps Relief Society, a charitable organization (EIN-53-0204618) doing business at 875 North Randolph Street, Suite 225, Arlington, VA 22203. I un-

derstand that this authorization may be revoked by me, by an allotment stoppage authorization, at any time before it expires and that it will be revoked automatically upon my separation from the service.

Contributions are tax deductible.

Contributor’s Signature

Date

Contributor’s Signature

Date

Key Person’s Signature

Copy 1: Forward to your ADFD Key Person

Copy 2:

Forward to your ADFD Key Person

Copy 3: Retain for your records