AUTHORIZATION FOR EMERGENCY EVACUATION ADVANCE AND ALLOTMENT PAYMENTS
FOR DOD CIVILIAN EMPLOYEES
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 5521-5527; E.O. 9397; E.O. 10982; E.O. 12107; and E.O. 12748.
PRINCIPAL PURPOSE(S): Information is collected to facilitate the issuance of emergency evacuation advance and allotment payments to a
DoD civilian employee.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in delay in approval of the authorization.
2. SOCIAL SECURITY NO.
3. GRADE OR LEVEL
4. STEP OR RATE
1. SPONSORING CIVILIAN EMPLOYEE
a. NAME (First, Middle Initial, Last)
5. POSITION TITLE
b. ADDRESS (Street, City, State and Zip Code)
6. EMPLOYING DEPARTMENT
7. APPROPRIATION
8. EVACUATED INSTALLATION
9. EVACUATION ORDER
10. DATE OF ORDER
11.
DATE EVACUATED
NO.
(YYYYMMDD)
(YYYYMMDD)
12. NAME OF DEPENDENT OR DESIGNATED REPRESENTATIVE
13. RELATIONSHIP
(First, Middle Initial, Last)
14. OTHER DEPENDENTS
(If additional space is needed, use back.)
b. DATE OF BIRTH
b. DATE OF BIRTH
a. NAME
a. NAME
(YYYYMMDD)
(YYYYMMDD)
$
$
per pay period and/or advance of pay of
to dependent named
15. I hereby authorize payment of
above or designated representative. I understand that funds paid will be charged against any items of pay or allowances due or to
become due me after date of payment.
16. I hereby authorize dependent named above or designated representative to receive payments indicated:
$
$
a. EVACUATION SUBSISTENCE ALLOWANCE:
b. EVACUATION TRAVEL AND TRANSPORTATION:
17. EMPLOYEE
a. SIGNATURE
b. DATE SIGNED (YYYYMMDD)
18. DEPENDENT OR DESIGNATED REPRESENTATIVE
a. SIGNATURE
b. DATE SIGNED (YYYYMMDD)
19. AUTHORIZED OFFICIAL
a. TYPED NAME
b. TITLE
c. SIGNATURE
d. DATE SIGNED (YYYYMMDD)
$
20. I request the amount of
per pay period as an allotment or assignment of monies due dependent named above
(to be completed only when, because of emergency conditions, certification by employee is not available). I (dependent or designated
representative named above) certify that the above information is complete and accurate to the best of my knowledge and belief.
a. SIGNATURE
b. DATE SIGNED (YYYYMMDD)
21. PAYMENT RECORD
(If additional space is needed, use back.)
a. DATE
b. PAID BY (ADSN)
c. VOUCHER NO.
d. TYPE OF PAYMENT
e. AMOUNT
(YYYYMMDD)
DD FORM 2461, MAR 2000
PREVIOUS EDITION IS OBSOLETE.
PRINT
RESET
1
Dd Form 2891 - Authorization For Retired Serviceman's Family Protection Plan (rsfpp) And/or Survivor Benefit Plan (sbp) Costs Deduction Supplemental Instructions
Business
