B. Signature of Officer Responsible for Preparation of Payroll
(Type Name and Sign all Copies)
Date
5. Employee or Social Security Number
I hereby request and authorize a regular allotment to be made, changed, discontinued, subject to approval, to be effective as
indicated above, until altered by me in writing; or, an emergency evacuation allotment to be effective when countersigned by me, or if absent
from the Post at time of evacuation, by the Post Administrative Officer; and I hereby release whatever claim to payment of salary I would
otherwise have for the amount of this allotment and I also relinquish all right, privilege, and power to make a further allotment presented by this
allotment, once the United States has issued a check payable to the allottee for this allotment.
Emergency Evacuation Allotment
U.S. Department of State
ALLOTMENT OF PAY/PRIOR SERVICE CREDIT (FOREIGN SERVICE EMPLOYEES)
APPLICATION AND AUTHORIZATION TO MAKE, CHANGE, OR DISCONTINUE
1. U.S. Department or Agency 2. Bureau or Service
4. Name of Allotter (Last, First, MI.)
3. Retirement System
6. Duty Station
(City) (Country)
7. NATURE OF ACTION REQUESTED
FS Prior Service Credit
From:Allotment Each
Pay Period
DS-1992
05-2006
8. AUTHORIZATION BY ALLOTTER
Type of Depositor Account
Depositor Account Number
Name and Address of Financial Institution
Routing/EIN Number
Saving
FSR
FSPS
Allotment of Pay
To:
Checking
Date
Date
Other
If FS Prior Service Credit box is selected: use "977770000003" as the Routing/EIN number, and "__X8186.3" as the account number below.
A. Title of Officer Responsible for Preparation of Payroll
WARNING: Disclose to Authorized Persons Only (22 CFR 171.32J(4)) Contains Information Protected by the PRIVACY ACT OF 1974
Appropriation
9. ADMINISTRATIVE ACTION
A. Signature of Allotter in Full (Sign Original Only)
B. Countersigned (Allotter - Administrative Officer)
10. APPROVED, RECORDED, AND FORWARDED
(mm-dd-yyyy)
(mm-dd-yyyy)
(mm-dd-yyyy)
click to sign
signature
click to edit
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