Form PHS-7033 Special Pay Contract - Accession Bonus

Form PHS-7033 is a U.S. Department of Health and Human Services form also known as the "Special Pay Contract - Accession Bonus". The latest edition of the form was released in February 1, 2006 and is available for digital filing.

Download a fillable PDF version of the Form PHS-7033 down below or find it on U.S. Department of Health and Human Services Forms website.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
SPECIAL PAY CONTRACT - ACCESSION BONUS
(Privacy Act Notice on Reverse)
IDENTIFICATION
DCP USE ONLY
NAME (Last, First, Middle Initial)
GRADE/RANK
DATE REC.
CT. DATE
PHS SERIAL NUMBER
ORGANIZATION
DUTY PHONE NUMBER
SSAN
EXP. DATE
CONDITIONS OF CONTRACT
In consideration of payment of an Accession Bonus for which I qualify under 37 U.S.C. 302d, 302h, or 302i, I hereby agree to the
following:
A. To remain on active duty in the Public Health Service (PHS) Commissioned Corps for 48 consecutive months from the effective
date of this contract.
B. That the effective date of this contract will be the date of call to active duty (CAD), if the signed and notarized contract is received
in the Compensation Branch (CB), Division of Commissioned Personnel (DCP), within 60 days of the CAD.
(NOTE: The Accession Bonus will not be paid until the required license is obtained. The license must be obtained within 1 year
of CAD.)
C. If this contract is terminated prior to its expiration date:
(1) I will be required to refund a pro rata portion of any payment received pursuant to this contract. The amount of the refund
shall be that portion of the payment (1/1440th of the 4 year contract) for each day of the agreed-to period not served; and
(2) Any amount which I am obligated to refund because this contract is terminated will 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 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.
D. That a period of Absence Without Leave (AWOL) shall not be credited toward fulfillment of the active-duty obligation incurred
pursuant to this contract and that the period of such active-duty obligation shall be extended by the number of days of AWOL.
E. That I am not serving a training-related service obligation as a result of Department of Health and Human Services
(HHS)-supported financial assistance.
F. That the policies (INSTRUCTION 7 and INSTRUCTION 8, Subchapter CC22.2, of the Commissioned Corps Personnel Manual)
which implement the provisions of 37 U.S.C. 302d, 302h, and 302i, are incorporated into and made part of this contract.
CERTIFICATION
I certify that I understand and agree to the terms of this contract as stated above.
SIGNATURE
DATE
NOTARIZATION
Subscribed and sworn before me this
day of
, A.D.,
at
(year)
City
State
Zip Code
.
SIGNATURE
DATE COMMISSION EXPIRES
AGENCY / OPERATING DIVISION / PROGRAM CERTIFICATION
I certify that this officer is not currently serving a training-related service obligation as a result of HHS-supported financial assistance, and I recommend
payment of the Accession Bonus.
NAME (Print or Type)
SIGNATURE
DATE
TITLE
ORGANIZATION
PHONE NO.
PHS-7033 (Rev. 02/06)
EF
PSC Publishing Services (301) 443-6740
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
SPECIAL PAY CONTRACT - ACCESSION BONUS
(Privacy Act Notice on Reverse)
IDENTIFICATION
DCP USE ONLY
NAME (Last, First, Middle Initial)
GRADE/RANK
DATE REC.
CT. DATE
PHS SERIAL NUMBER
ORGANIZATION
DUTY PHONE NUMBER
SSAN
EXP. DATE
CONDITIONS OF CONTRACT
In consideration of payment of an Accession Bonus for which I qualify under 37 U.S.C. 302d, 302h, or 302i, I hereby agree to the
following:
A. To remain on active duty in the Public Health Service (PHS) Commissioned Corps for 48 consecutive months from the effective
date of this contract.
B. That the effective date of this contract will be the date of call to active duty (CAD), if the signed and notarized contract is received
in the Compensation Branch (CB), Division of Commissioned Personnel (DCP), within 60 days of the CAD.
(NOTE: The Accession Bonus will not be paid until the required license is obtained. The license must be obtained within 1 year
of CAD.)
C. If this contract is terminated prior to its expiration date:
(1) I will be required to refund a pro rata portion of any payment received pursuant to this contract. The amount of the refund
shall be that portion of the payment (1/1440th of the 4 year contract) for each day of the agreed-to period not served; and
(2) Any amount which I am obligated to refund because this contract is terminated will 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 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.
D. That a period of Absence Without Leave (AWOL) shall not be credited toward fulfillment of the active-duty obligation incurred
pursuant to this contract and that the period of such active-duty obligation shall be extended by the number of days of AWOL.
E. That I am not serving a training-related service obligation as a result of Department of Health and Human Services
(HHS)-supported financial assistance.
F. That the policies (INSTRUCTION 7 and INSTRUCTION 8, Subchapter CC22.2, of the Commissioned Corps Personnel Manual)
which implement the provisions of 37 U.S.C. 302d, 302h, and 302i, are incorporated into and made part of this contract.
CERTIFICATION
I certify that I understand and agree to the terms of this contract as stated above.
SIGNATURE
DATE
NOTARIZATION
Subscribed and sworn before me this
day of
, A.D.,
at
(year)
City
State
Zip Code
.
SIGNATURE
DATE COMMISSION EXPIRES
AGENCY / OPERATING DIVISION / PROGRAM CERTIFICATION
I certify that this officer is not currently serving a training-related service obligation as a result of HHS-supported financial assistance, and I recommend
payment of the Accession Bonus.
NAME (Print or Type)
SIGNATURE
DATE
TITLE
ORGANIZATION
PHONE NO.
PHS-7033 (Rev. 02/06)
EF
PSC Publishing Services (301) 443-6740
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
Rockville, Maryland 20857-0001
Privacy Act Notice for Form PHS-7033
PHS Commissioned Corps Special Pay Contract - Accession Bonus
Records System:
09-40-0001, PHS Commissioned Corps General Personnel Records, HHS/PSC/HRS
09-40-0003, PHS Commissioned Corps Board Proceedings, HHS/PSC/HRS, and
09-40-0010, Pay, Leave, and Attendance Records, HHS/PSC/HRS.
General: This information is provided pursuant to the Privacy Act of 1974 (Public Law 93-579)
for PHS Commissioned Corps officers applying for an Accession Bonus.
Authority for Collection of Information: 37 U.S.C. 302b (Pay and Allowances of the
Uniformed Services); 42 U.S.C. 202 et seq. (PHS Act Sec 201 et seq.); and Executive Order
9397 (Numbering System for Federal Accounts Relating to Individual Persons).
Purposes and Uses: The principal purpose for collecting this information is to determine your
eligibility for an Accession Bonus. If you are selected for award of an Accession Bonus, the
information collected will be used for issuance of personnel orders to authorize payment.
These records, or information therefrom, may also be provided to other Federal agencies to
which PHS Commissioned Corps officers are assigned. The information also may be used for
study purposes and/or collection of statistical data for reports to other Federal agencies and
the Congress. It may also be used for other lawful purposes including collection of a debt
owed the Federal government, law enforcement, and litigation.
Information Regarding Disclosure of Your Social Security Number (SSN): Disclosure of
the SSN is mandatory under provisions of the Social Security Act, since PHS Commissioned
Corps officers are under Social Security "covered employment" and taxes must be withheld
from their salaries. The SSN is also used as an identifier throughout an officer’s career. It is
used primarily to identify an officer’s personnel, leave, and pay records and to relate one to
the other. The SSN is also used in connection with lawful requests for information from former
employers, educational institutions, and financial or other organizations. The information
gathered through the use of the number will be used only as necessary in personnel
administration processes carried out in accordance with established regulations and
published notices of systems of records. The use of the SSN is made necessary because of
the large number of present and former active, inactive, and retired officers and applicants
who have identical names and birth dates, and whose identities can only be distinguished by
the SSN.
Effect of Nondisclosure: You are required to provide the information requested on this
contract to receive an Accession Bonus. Failure to supply complete and accurate information
may result in delays and/or errors in determining eligibility and, therefore, result in late payment
or non-payment, or be cause for refund of pay if you receive an award based on erroneous
information. All statements are subject to verification.
PHS-7033 (Rev. 02/06)

Download Form PHS-7033 Special Pay Contract - Accession Bonus

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