Uniformed Services Benefit Association  

Active Duty Air Force or Navy:
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:

PAYEE:

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: N160304
   
Signature:
Date Signed: