DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
SAMPLE MEMORANDUM
TO REQUEST PAYMENT OF A UNIFORM ALLOWANCE
FROM DATE SUBJECT
Request for Uniform Allowance
Deliver to: Division of Commissioned Corps Personnel and Readiness
ATTN: Compensation
1101 Wootton Parkway, Plaza Level, Suite 100
Rockville, MD 20852
In a memorandum dated April 6, 1987, the Surgeon General has directed me to own and wear the appropriate Public Health Service
(PHS) Commissioned Corps uniform. Under the provisions in Instruction 612.03 “Uniform and Equipment Allowance” of the
Commissioned Corps Issuance System (CCIS), I hereby apply for the uniform and equipment allowance in the amount of $250.00.
I certify that I have not at any time previously received a PHS Commissioned Corps uniform allowance under the provisions of 37 U.S.C
415 (c). I understand that making a false statement or claim against the U.S. Government is punishable by a fine of not more than
$10,000 or imprisonment for not more than 5 years or both (Act of June 25, 1948, 18 U.S.C. 287, 1001).
SIGNATURE TEMPORARY GRADE
SOCIAL SECURITY NUMBER (SSN)
(Rev. 8/16)
PSC Publishing Services (301) 443-6740
EF
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