
Signature of Alloter ADMINISTRATIVE ACTION For Payroll Use Only Processed Verified PHS-6173 Rev. 3/05 FRONT PSC Media Arts 301 443-1090 EF Application for Allotment of Pay -- PHS-6173 Privacy Act Notification Statement General The following information about this form and its uses is provided to you as required by the Privacy Act of 1974 5 U.S.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Commissioned Corps For Payroll Use Only APPLICATION FOR ALLOTMENT OF PAY Please read Privacy Act Statement on back before completing this form Deliver to Office of Commissioned Corps Support Services ATTN Compensation Branch 5600 Fishers Lane Room 4-50 Rockville MD 20857-0001 1. Name Last First Middle 2. Date 3. Social Security Number Type or Print 4. Address 5. City 6. State 7. Zip Code 9. Purpose 8. Work Phone Number 10. Account Number if applicable Insurance Charity Dependent Support 11. Allotment Recipient 12. Check One Box Initial Authorization Amount Name Increase Allotment To....
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How to fill out the PHS-6173 online
This guide provides clear instructions on how to complete the PHS-6173 form, a crucial document for authorizing the allotment of pay within the Public Health Service Commissioned Corps. By following these steps, you can efficiently fill out the form online, ensuring your information is accurate and submitted correctly.
Follow the steps to complete your PHS-6173 form online.
- Click ‘Get Form’ button to access the PHS-6173 form and open it in the online editor.
- Fill in your name in the format of Last, First, and Middle in the designated field. Ensure that the spelling and order are correct.
- Enter the current date in the provided section. This should be the date on which you are completing the form.
- Input your Social Security Number in the specified field. It is crucial to provide this information accurately for identification purposes.
- Provide your complete address, including street name and number, city, state, and zip code in the respective fields.
- Fill out your work phone number in the designated space to ensure the appropriate contact can reach you if necessary.
- If applicable, enter your account number related to the allotment you are requesting.
- Select the purpose of the allotment from the available options: insurance, charity, or dependent support.
- Indicate the allotment recipient's name and address in the respective fields.
- Choose one option from the checkbox section to indicate whether this is an initial authorization amount, an increase, a decrease, or cancellation of the allotment.
- State the effective date for the action you are requesting.
- Read and acknowledge the request and authorization statement, then provide your signature in the appropriate section to confirm your authorization.
- Once you have reviewed the entire form for accuracy, you can save your changes, download the completed form, print it, or share it as necessary.
Complete your PHS-6173 online to ensure a smooth processing of your pay allotment.
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How do they verify community service hours?
Verification of community service hours typically involves a confirmation process by the supervising organization. They may require a signed form that outlines the hours served and specific tasks completed. Keep in mind that for requirements centered around PHS-6173, having credible documentation is vital for successful verification of your hours.
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