Uniformed Services Benefit Association  

Retired Air Force, Army, Marines or Navy:
Start a New 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 START my allotment as outlined below:

PAYEE:

Uniformed Services Benefit Association
PO Box 25956
Overland Park, KS 66225-0956

 Allotment Start Amount:
(Exact Amount of your USBA Premium)

Effective Date: IMMEDIATELY
Reason: Insurance Premium
Group Policy Number: Use SSN
Blanket Company Code: 194
   
Signature:
Date Signed: