Uniformed Services Benefit Association  

Retired Air Force, Army, Marine Corps or Navy:
Change an Existing Allotment Deduction

Print and fill out this form, then mail to the below address or FAX to the Finance Center
at (800) 469-6559:

DFAS
US Military Retired Pay
PO BOX 7130
London, KY 40742-7130


Name (Please Print):
Social Security Number:

Please CHANGE my allotment as outlined below:

PAYEE:

Uniformed Services Benefit Association
PO Box 25956
Overland Park, KS 66225-0956
Amount of Current Allotment:
(From LES Statement)
Amount of New Allotment:
(Exact Amount of your USBA premium)
Effective Date: IMMEDIATELY
Reason: Insurance Premium
Group Policy Number: Use SSN
Blanket Company Code: 194
   
Signature:
Date Signed: