Form Phs-7039 - Application For Allotment Of Pay

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For Payroll Use Only
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
Division of Commissioned Personnel
APPLICATION FOR ALLOTMENT OF PAY
(For Additional Montgomery G.I. Bill Benefits)
Please read Privacy Act Statement on back
before completing this form.
Deliver to: Division of Commissioned Personnel
ATTN: Veterans Education Assistance
5600 Fishers Lane, Room 4-20
Rockville, MD 20857-0001
1. NAME (Last, First, Middle)
2. DATE
3. SOCIAL SECURITY NUMBER
4. ADDRESS
5. CITY
6. STATE
7. ZIP CODE
8. WORK PHONE NUMBER (Include
Area Code)
9. CHECK ONE BOX
Lump Sum Payment of $600. Personal check is attached and made out to the Department of Health
and Human Services. No deduction from pay will be made.
Lump sum Payment of $____________ and deduct $__________ from pay for _____ months to =
$600. Personal check is attached and made out to the Department of Health and Human Services.
Deduction must be a multiple of $4 and a minimum of $24.
Deduct $__________ per month for _____ months (must equal $600).
Deduction must be a multiple of $4 and a minimum of $24.
10. REQUEST AND AUTHORIZATION
I hereby request and authorize the above pay allotment to be initiated.
SIGNATURE OF ALLOTTER
DATE
ADMINISTRATIVE ACTION (For DCP Use Only)
OSB Clearance
Processed
Verified
PHS-7039 (3/02)
FRONT
EF

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