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Retired Coast Guard
COMMANDING OFFICER (RPD)
COAST GUARD PAY/PERSONNEL CTR
444 SE QUINCY ST
TOPEKA, KS 66683-3591
Mail this form to the above address or FAX to the Finance Center at 1-785-295-2638.
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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: |
086 |
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Signature: |
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Date Signed: |
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