"Contribution Form - the Secretary of the Navy's Active Duty Fund Drive in Support of the Navy-Marine Corps Relief Society"

Contribution Form - the Secretary of the Navy's Active Duty Fund Drive in Support of the Navy-Marine Corps Relief Society is a 2-page legal document that was released by the U.S. Department of the Navy and used nation-wide.

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| USMC Code: 954 USN Code: T602886
| USMC Code: 954 USN Code: T602886
Contribution Form
DFAS INFO | USMC Code: 954 USN Code: T602886
secretary of the navy’s
active duty fund drive
F
M
i
F
M
i
First Name
_______________________
M.I.
______
Last
_____________________________
in support of the
i
S
S
-
-
Pay Grade
_________
SSN
S
____________________________________________
EDIPI
__________________________________________
_________________
(DFAS Requires SSN or EDIPI on Allotments Only)
Homeport / Station ___________________________________________________________________________
Help support Shipmates, fellow Marines and their families.
Command / UIC / RUC _______________________________________________________________________
Someday you may need them to return the favor.
EAOS / EAS (month / day / year) ______________________________________
/
/
Active Duty USMC
Retired USN*
Retired USMC*
Other
M
Active Duty USMC
Retired USN*
Retired USMC*
Other
M
Status
Active Duty USN
Active Duty USMC
Active Duty USMC
Retired USN*
Retired USN*
Retired USMC*
Retired USMC*
Other
Other
Monthly Payroll Allotment
Other Ways to Give
*Forward copy 1 to NMCRS HQ
$10
$25
$35
check $ ____________
credit card $ __________________
$50
$100
other ___________
cash $ ______________
one-time charge
recurring/monthly charge
www.nmcrs.org/adfd
this 12-month allotment totals $
total check, cash or credit card contribution $
For allotments only: I hereby authorize the Department of the Navy to deduct the indicated amount from my pay each month for twelve (12) months starting June 1 and ending May 31 of the following year, pro-
vided that the amount deducted be remitted to the Navy-Marine Corps Relief Society, a charitable organization (EIN-53-0204618) doing business at 875 North Randolph Street, Suite 225, Arlington, VA 22203. I un-
derstand that this authorization may be revoked by me, by an allotment stoppage authorization, at any time before it expires and that it will be revoked automatically upon my separation from the service.
Contributions are tax deductible.
Contributor’s Signature
Date
Contributor’s Signature
Date
C
Key Person’s Signature
Key Person’s Signature
K
Copy 1: Forward to your ADFD Key Person
Copy 2:
Forward to your ADFD Key Person
Copy 3: Retain for your records
C
| USMC Code: 954 USN Code: T602886
| USMC Code: 954 USN Code: T602886
Contribution Form
DFAS INFO | USMC Code: 954 USN Code: T602886
secretary of the navy’s
active duty fund drive
F
M
i
F
M
i
First Name
_______________________
M.I.
______
Last
_____________________________
in support of the
i
S
S
-
-
Pay Grade
_________
SSN
S
____________________________________________
EDIPI
__________________________________________
_________________
(DFAS Requires SSN or EDIPI on Allotments Only)
Homeport / Station ___________________________________________________________________________
Help support Shipmates, fellow Marines and their families.
Command / UIC / RUC _______________________________________________________________________
Someday you may need them to return the favor.
EAOS / EAS (month / day / year) ______________________________________
/
/
Active Duty USMC
Retired USN*
Retired USMC*
Other
M
Active Duty USMC
Retired USN*
Retired USMC*
Other
M
Status
Active Duty USN
Active Duty USMC
Active Duty USMC
Retired USN*
Retired USN*
Retired USMC*
Retired USMC*
Other
Other
Monthly Payroll Allotment
Other Ways to Give
*Forward copy 1 to NMCRS HQ
$10
$25
$35
check $ ____________
credit card $ __________________
$50
$100
other ___________
cash $ ______________
one-time charge
recurring/monthly charge
www.nmcrs.org/adfd
this 12-month allotment totals $
total check, cash or credit card contribution $
For allotments only: I hereby authorize the Department of the Navy to deduct the indicated amount from my pay each month for twelve (12) months starting June 1 and ending May 31 of the following year, pro-
vided that the amount deducted be remitted to the Navy-Marine Corps Relief Society, a charitable organization (EIN-53-0204618) doing business at 875 North Randolph Street, Suite 225, Arlington, VA 22203. I un-
derstand that this authorization may be revoked by me, by an allotment stoppage authorization, at any time before it expires and that it will be revoked automatically upon my separation from the service.
Contributions are tax deductible.
Contributor’s Signature
Date
Contributor’s Signature
Date
C
Key Person’s Signature
Key Person’s Signature
K
Copy 1: Forward to your ADFD Key Person
Copy 2:
Forward to your ADFD Key Person
Copy 3: Retain for your records
C
secretary of the navy’s
secretary of the navy’s
active duty fund drive
active duty fund drive
in support of the
in support of the
privacy act statement
Principal Purposes and Routine Uses
Information Regarding Disclosure of Your
privacy act statement
Principal Purposes and Routine Uses
Information Regarding Disclosure of Your
This form is used as the authority to make
Social Security Number Under the Privacy Act,
This form is used as the authority to make
Social Security Number Under the Privacy Act,
General
Section 7(b)
General
Section 7(b)
deductions from service member’s pay and
deductions from service member’s pay and
This information is provided pursuant to the
transmit such amounts to the Navy-Marine
Disclosure by you of your social security number
This information is provided pursuant to the
transmit such amounts to the Navy-Marine
Disclosure by you of your social security number
Privacy Act 1974 (5 U.S.C. 52a) for individuals
Privacy Act 1974 (5 U.S.C. 52a) for individuals
Corps Relief Society. This information will be
may be deemed mandatory for the purpose of
Corps Relief Society. This information will be
may be deemed mandatory for the purpose of
who complete the contribution form for the
who complete the contribution form for the
payroll deductions for contributions. Solicitation
payroll deductions for contributions. Solicitation
Navy-Marine Corps Relief Society.
Navy-Marine Corps Relief Society.
Navy and Marine Corps Finance Center.
of the social security number is an authorized
Navy and Marine Corps Finance Center.
of the social security number is an authorized
provision of Executive Order 9397.
provision of Executive Order 9397.
Authority
Authority
Effects of Nondisclosure
Effects of Nondisclosure
Executive Order 12353 authorized solicitation
Executive Order 12353 authorized solicitation
The disclosure of this information is voluntary;
SAFEGUARD PERSONALLY
The disclosure of this information is voluntary;
SAFEGUARD PERSONALLY
by members of the armed forces in support
by members of the armed forces in support
however, payroll deductions and payments to
however, payroll deductions and payments to
INDENTIFIABLE INFORMATION
INDENTIFIABLE INFORMATION
of their own members. 5 C.F.R. Part 950, and
the Navy-Marine Corps Relief Society cannot
of their own members. 5 C.F.R. Part 950, and
the Navy-Marine Corps Relief Society cannot
SECNAVINST 5340.7.
FROM UNAUTHORIZED
SECNAVINST 5340.7.
FROM UNAUTHORIZED
be made without a completed form.
be made without a completed form.
DISCLOSURE
DISCLOSURE
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