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Active Duty Marines
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)
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(Complete
amount below)
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Amount of New
Allotment:
(Exact Amount of
your USBA premium)
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Effective Date:
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IMMEDIATELY
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Reason:
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Insurance Premium
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Group Policy Number:
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Use SSN
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Blanket Company Code:
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102
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Signature:
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Date Signed:
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