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Retired Air Force, Army, Marines, or Navy
DFAS
US Military Retired Pay
PO BOX 7130
London, KY 40742-7130
Mail this form to the above address or FAX to the Finance Center at 1-800-469-6559.
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Name: (Please Print) |
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Social Security Number: |
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Please START my allotment as outlined below:
PAYEE:
Uniformed Services Benefit Association
PO Box 25956
Overland Park, KS 66225-0956
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Allotment Start Amount:
(Exact Amount of your USBA Premium) |
(Complete amount below) |
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Effective Date: |
IMMEDIATELY |
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Reason: |
Insurance Premium |
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Group Policy Number: |
Use SSN |
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Blanket Company Code: |
194 |
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Signature: |
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Date Signed: |
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