Phs-6173 - Application For Allotment Of Pay - Commissioned Corps Management (Page 2 of 2) in pdf

Phs-6173 - Application For Allotment Of Pay - Commissioned Corps Management Page 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service Commissioned Corps

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. 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.

2. To respond to court orders from the Internal Revenue Service for garnishment of an employee’s pay

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.

PHS-6173

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(Rev. 3/05)

Phs-6173 - Application For Allotment Of Pay - Commissioned Corps Management Page 2