Fillable Phs-4013-1 FORM PHS 4013-1

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Phs-4013-1 FORM PHS 4013-1

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Department of Health and Human Services
Public Health Service Commissioned Corps
APPLICATION FOR SHIPMENT OF HOUSEHOLD GOODS (COMMISSIONED OFFICERS)
Type or print. Forward the original (with signature) to the PHS Shipping Officer serving your station. Retain a copy for your records.
1. TO: (Name and Address of Shipping Officer) (Type or print) 2. FROM: (Last name, first name, middle initial, and rank of applicant)
3. TELEPHONE NO. (Applicant)
OFFICE
HOME
4. PRESENT PERMANENT DUTY STATION (Operating Division, Bureau, Division, City, State, Zip)
5.
I hereby request that my household goods be transported as authorized by attached copy of
PERSONNEL ORDER TRAVEL ORDER
NUMBER
DATED
NO. ROOMS APPROX. WT.
THIS ORDER AUTHORIZES SHIPMENT TO (City and State)
This order DOES
DOES NOT
separate or inactivate me from active duty.
6.
(a) I have previously shipped under order listed in Item 5 above
YES
NO
(b) If YES, list shipment(s) made below
DATE FROM TO
G.B.L. NO.
(If known)
WT. SHIPPED
(If known)
7. SHIPMENT TO BE MADE FROM (Street Address, City, State, Zip)
8. TO BE SHIPPED TO (StreetAddress,City, State,Zip) 9. DATE REQUESTED FOR PICKUP
10. DESIRED DATE OF APPROVAL
11. EXTRA LOCAL PICKUP (Street Address, City, State, Zip) 12. EXTRA LOCAL DELIVERY (Street Address, City, State, Zip)
13. MY MAILING ADDRESS WHILE GOODS ARE IN TRANSIT
WILL BE
14. PERSON TO RECEIVE GOODS AT DESTINATION OR
DESIGNATED AGENT
15. I REQUEST THAT MY GOODS BE
PLACED IN STORAGE AT (City and
State)
16. REMARKS OR ADDITIONAL INFORMATION
17. I certify that:
(a) The above requested shipment will consist of
household goods in my possession prior to
the effective date of my orders.
(b) The following items are necessary in the
performance of my official duties:
Professional books
Yes No
Professional papers
Yes No
Other (specify)
(c) The following appliances will need technical
servicing for safe transportation:
1.
2.
3.
4.
(d) I will immediately notify the origin shipping
officer if my orders are modified or cancelled
and affect this shipment.
(e) I will pay all excess costs incurred as a result
of this shipment. (This agreement will not
prejudice my right to appeal such costs after
payment is made.)
(f) I have not and will not make claim for trailer
allowance.
(g) Shipment of approximately
pounds
of my allowance by expedited mode is required to
carry out assigned duties or prevent undue hardship
to me and/or my dependents.
(Signature of Applicant)
(Date)
FOR ADMINISTRATIVE USE ONLY
REPRESENTATIVE CONTACTED DATE
REPRESENTING (Name of Company or Agent)
SHIPMENT CONFIRMED PER DATE PICK-UP DATE
G.B.L. NO. NAME OF TRANSPORTATION COMPANY
TENDERED TO (Name of Agent)
Lot/s Household Goods
Gross Tare Net
Weight includes lbs. professional books, papers, etc.
SIT-NTE 90 days at (Name, address, and telephone number of Agent)
Excess distance miles Excess charges
Excess weight pounds
Excess charges
Unauthorized services (specify)
Excess charges
Total amount to be paid by commissioned corps member to Shipping Officer prior
to shipment of goods (when appropriate).
REMARKS:
NOTES:
PHS-4013-1 (REV. 8/16)
FRONT
(See Privacy Act on reverse)
PSC Publishing Services (301) 443-6740
EF
click to sign
signature
click to edit
PRIVACY ACT STATEMENT
for
Form PHS-4013-1
Application for Shipment of Household Goods (Commissioned Officers)
General
This statement is provided pursuant to the Privacy Act of 1974 (P.L. 93-579).
Authority for Collection of Information
Section 406, Title 37, United States Code provides authority for collection of information.
Principal Purposes and Routine Uses
The information provided on this form will be used in processing the authorization to ship your household goods and/or one
privately-owned motor vehicle at the government's expense in connection with the change of duty station between the contiguous
United States and an non-continental United States assignment area and return.
The information provided on this form will not be disclosed outside the Department of Health and Human Services without written
consent, except as indicated below:
To prospective employers or other organizations at the request of the individual.
1.
To other Federal agencies in the event of appointment of former officers.
2.
To Department of Defense in event of national emergency.
3.
The Bureau of Prisons (Department of Justice), Coast Guard (Department of Transportation) and Environmental Protection
Agency may obtain copies of personnel documents relating to commissioned officer assignments to those agencies.
4.
Records may be disclosed to individuals and organizations deemed qualified by the Secretary to carry out specific
research solely for the purpose of carrying out such research (45 CFR, Part 5b, Appendix B, Item 101). Disclosure may
be made to a congressional office from the record of an individual in response to an inquiry from the congressional office
made at the request of that individual.
5.
In the event of litigation in which one of the parties is:
(a) The Department, any component of the Department, or any employee of the Department in his or her official capacity.
(b) The United States in which the Department determines that the claim, if successful, is likely to directly affect the
operations of the Department or any of its components.
(c) Any Department employee in his or her individual capacity in which the Justice Department has agreed to represent
such employee.
The Department may disclose such records as it deems desirable or necessary to the Department of Justice to enable that
Department to effectively represent such party, provided such disclosure is compatible with the purpose for which the records
were collected.
Effects of Nondisclosure
The disclosure of the information requested on this form is voluntary; However, if the form is not completed, it will not be possible
to process the shipment of your household goods and/or your motor vehicle at government expense.
PHS-4013-1 (REV. 8/16)
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Phs-4013-1 FORM PHS 4013-1

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Completed 27 February 2020

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