Uniformed Services Benefit Association  

Active Duty Marines:
Change an Existing Allotment Deduction

Print and fill out this form, then take to your Finance Officer.

Name (Please Print):
Social Security Number:

Please CHANGE my allotment as outlined below:


Uniformed Services Benefit Association
PO Box 25956
Overland Park, KS 66225-0956
Amount of Current Allotment:
(From LES Statement)
Amount of New Allotment:
(Exact Amount of your USBA premium)
Effective Date: IMMEDIATELY
Reason: Insurance Premium
Group Policy Number: Use SSN
Blanket Company Code: 102
Date Signed: