Active Duty - Contribution Allotment Authorization printable pdf download

Active Duty - Contribution Allotment Authorization

Coast Guard

Active Duty - Contribution

Mutual Assistance

Allotment Authorization

Name: Last

First

M.I.

Rate/Rank

Social Security Number

Employee ID #

XXX-XX

Home Address:

Street

Apt. No.

City

State

Zip Code

E-Mail Address

Unit Name:

YES!

I want to help Coast Guard people in their time of need!

Start

Please

a monthly allotment from my Coast Guard Pay to Coast Guard Mutual Assistance in the

amount of: $

effective (MM/YY)

Change

Please

my existing allotment to Coast Guard Mutual Assistance from $

to $

effective (MM/YY)

I hereby authorize this allotment to be taken from my Coast Guard Pay. I understand that it will

remain in effect until I request that it be changed or stopped.

Signature (Required):

Date:

Please sign and submit the completed form to CGMA Headquarters via one of the

following:

Scan the form and Email to CGMA-HQ at

HQS-DG-CGMA@uscg.mil

(Preferred)

Fax the form to: (703) 875-0344

Mail the form to:

Coast Guard Mutual Assistance

1005 N. Glebe Rd., Suite 220

Arlington, VA 22201

Thank you

for your tax-deductible contribution to Coast Guard Mutual Assistance!

CGMA Form 43 (Revised 08/16)

CGMA-HQ (800) 881-2462

Active Duty - Contribution Allotment Authorization

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