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Active Duty Army
TAKE THIS FORM TO YOUR FINANCE OFFICER
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Name: (Please Print) |
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Social Security Number: |
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Please CHANGE my allotment as outlined below:
PAYEE:
Uniformed Services Benefit Association
PO Box 25956
Overland Park, KS 66225-0956
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Amount of Current Allotment:
(From LES statement) |
(Complete amount below) |
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Amount of New Allotment:
(Exact Amount of your USBA premium) |
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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: |
K002756 |
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Signature: |
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Date Signed: |
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