Fill and Sign the School Pick Up Authorization Form

AUTHORIZATION TO START, STOP OR CHANGE AN ALLOTMENT PRIVACY ACT STATEMENT AUTHORITY: 37 U.S.C., E.O. 9397. PRINCIPAL PURPOSE: To permit starts, changes, or stops to allotments. To maintain a record of allotments and ensure starts, changes, and stops are in keeping with member’s desires. ROUTINE USES: Information may be released to computer service centers and other accounting services when such centers and services act as authorized agents of organizations specified by the member to receive allotments. Disclosure may be made to the Federal Reserve System when payment of allotment is made through the electronic fund transfer system to financial organizations. Records may also be disclosed to Congress; allottees, Secret Service; General Accounting Office, Federal, State and local courts; U.S. Treasury; and to the Department of Justice, in some cases for prosecution, civil litigation, or for investigative purposes. DISCLOSURE: Voluntary; however, failure to provide the requested information as well as the SSN may result in the member not being able to start, change, or stop allotments. AIR FORCE TO BE COMPLETED BY ALLOTTER 2. NAME OF ALLOTTER (Last, First, Middle Initial) (Print or type) MARINE CORPS ARMY NAVY 1. BRANCH OF SERVICE (X one) 5. ADDRESS OF ALLOTTER (Street or Box Number, City, State, ZIP Code) 6. DAYTIME TELEPHONE NUMBER (Include Area Code) 3. SSN 4. PAY GRADE 7. EFFECTIVE DATE (YYYYMM) 8. MONTHLY AMOUNT OF ALLOTMENT $ 9. NAME OF ALLOTTEE (First, Middle Initial, Last) 11. TERM IN MONTHS 10. ALLOTMENT ACTION (X one) START 12. CREDIT LINE (If applicable) STOP CHANGE 13. ALLOTMENT CLASS AUTHORIZED (X one) C - CHARITY/CFC D - DISCRETIONARY ALLOTMENTS (Includes dependent support, payment to financial institution, insurance, repayment of home loan, rent, etc. (Notes 1 and 2)) 14. ALLOTTEE’S MAILING ADDRESS (Street or Box Number, City, State, ZIP Code) F - CHARITY - EMERGENCY/ASSISTANCE FUND CONTRIBUTION L - REPAYMENT OF LOAN TO SERVICE ORGANIZATION (Red Cross, Relief Society, etc. - Navy and Marine Corps only) 15. IF FOREIGN ADDRESS COMPLETE AS FOLLOWS (Province, Country) N - NSLI OR USGLI INSURANCE PREMIUM T - PAYMENT OF DEBTS TO U.S., DELINQUENT STATE OR LOCAL INCOME/ EMPLOYMENT TAXES 16. REMARKS - OTHER (Specify) 17. COMPANY CODE/FINANCIAL INSTITUTION/ROUTING TRANSIT NUMBER 18. ACCOUNT NUMBER/POLICY NUMBER 19. TOTAL CLASS L AMOUNT $ 20. TOTAL CLASS T AMOUNT $ STATEMENT OF UNDERSTANDING I understand that this allotment is legal and that by voluntarily completing this form, I am responsible for: - Ensuring that the information is correct; - Reviewing my Leave and Earnings Statement to ensure the allotment stops, starts, or changes as directed including amount and payee; - Collecting overpayments from the receiver (payee) of the allotment, if I do not change or stop the allotment after a loan is repaid; - Contacting the receiver (payee) of the allotment, at my expense, to obtain monthly statements for my personal records. I also understand that any problems once the allotment is delivered to the receiver (payee) are beyond the control of the Defense Finance and Accounting Service (DFAS) and that DFAS is only responsible for ensuring proper delivery of any voluntary allotment for the period directed. I further understand that pursuant to conditions listed in the DoD 7000.14-R, Volume 7A, changes can be made by DFAS to an allottee’s name, address, or account number. 22. DATE (YYYYMMDD) 21. SIGNATURE OF ALLOTTER NOTE 1. Must be different address than allotter. Each dependent allotment must have a different credit line. Only one support allotment per dependent is allowed. NOTE 2. This is a voluntary allotment and can be to any payee you desire. DD FORM 2558, NOV 1996 (EG) PREVIOUS EDITION IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, Nov 96