DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
RETENTION BONUS (RB) AGREEMENT REQUEST
(Privacy Act Notice is on the Second Page)
IDENTIFICATION
NAME (Last, First, Middle Initial)
GRADE/RANK
PHS SERIAL NUMBER ORGANIZATION
DUTY PHONE NUMBER E MAIL
DCCPR USE ONLY
DATE REC’D.
SPECIAL PAY REQUESTED (Check appropriate box)
RETENTION BONUS (RB)
2 year agreement
RETENTION BONUS (RB)
3 year agreement
RETENTION BONUS (RB)
4 year agreement
CONDITIONS OF AGREEMENT
In consideration of payment of the RB for which I qualify in accordance with 37 U.S.C. 335; Commissioned Corps Directive (CCD)
151.05; and Commissioned Corps Instruction (CCI) 633.01, I hereby agree to the following:
A. To remain on active duty in the Corps for the agreement period specified above, commencing on the following date:
.
I understand that the effective date of this agreement will be the date determined by procedures set forth by the SG in a Personnel
Operations Memorandum (POM).
B.
That I will be paid RB in the amount specified for my category of
and with a specialty in
for each year of obligation.
C.
That I hold a current, valid and unrestricted license as directed for my category under CCI 251.01 "Professional Licensure and
Certification" or certification as required by CCI 231.01, "General Appointment Standards." I agree to remain certified in the
specialty referenced in section B, above, during the period I receive RB.
D.
That I will receive the RB in annual
lump sum payments
.
E.
That if I fail to complete the period of service for which RB is paid:
(1) Under the provisions contained in Sections 6-7.e. of CCI 633.01, I will be required to refund a pro rata portion of the payment
received which represents the unearned portion of that annual payment of a terminated agreement in accordance with 37
U.S.C. 373.
(2) The required repayment of the RB agreement consists of that portion that represents 1/360 of the annual payment for each
day of the year not earned;
(3) I shall be divested of entitlements for travel and transportation allowances for myself and my dependents; shipment of
household goods; and use of, transfer of, or payment for unused annual leave to my credit upon separation from the PHS
Commissioned Corps;
(4) Any amount which I am obligated to refund because this agreement is terminated shall be a debt due to the United States
which I hereby agree to pay in full as directed by the appropriate collections officials in accordance with CCI 654.02,
“Collection of Commissioned Officer Indebtedness Upon Separation.” In accordance with Treasury Fiscal Requirements
Manual (1 TFRM 6-8000, Cash Management), late charges may be assessed for payments made after the due date on
amounts owed to the United States Government; and I shall have my commission terminated.
(5) That I may not be eligible for recommissioning in the Corps.
F.
If I am not eligible to receive base pay because of a period of Absence Without Leave (AWOL), then I am not eligible for RB for
the duration of the AWOL and I am required to repay the prorated portion of any amount paid during the period of AWOL and my
obligation will be extended for an equal period of time as the AWOL.
G. That if I enter a long-term training program as defined in CCI 325.01, “Extramural Training” and CCI 325.02, "Intramural
Residency Training Programs,” or medical internship or residency training program (i.e., training which is creditable toward board
certification) this agreement shall be terminated and I shall repay an amount as specified in E.(1) above.
H.
That I am NOT ELIGIBLE for voluntary retirement for the duration of this agreement.
I. Payment of RB will normally commence within 90 days after receipt of the completed agreement in DCCPR or within 90 days
after DCCPR receives all necessary supporting documentation.
PHS-6189-1 (Rev. 12/18)
PSC Publishing Services (301) 443-6740
EF
