This election will remain in effect until changed by you. FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT CG-4700 12/17 Reset Page 1 of 4 SECTION IV DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY I hereby designate the following beneficiary ies to receive retired pay due and payable at my death. DEPARTMENT OF HOMELAND SECURITY U*S* Coast Guard COAST GUARD PHS NOAA RETIRED PAY ACCOUNT WORKSHEET AND SURVIVOR BENEFIT PLAN ELECTION Privacy Act Statement Authority Collection of this information is authorized by 10 U*S*C. Chapters 73 and 165 DOD Financial Management Regulation Volume 7B Chapters 14 30 49 and 54 and E*O. 9397. Purpose The Coast Guard Pay Personnel Center will use this information to establish a retired pay account including designation of beneficiaries for unpaid retired pay election information under the Survivor Benefit Plan SBP and federal and state tax withholding elections. Routine Uses The information will be used by the Coast Guard Pay Personnel Center to establish a retired pay account. The information may be shared with the Internal Revenue Service for tax purposes and with the Department of Veterans Affairs in conjunction with administration of DVA compensation* Disclosure Disclosure of this information including our beneficiary s SSN is voluntary however failure to furnish the requested information will result in delays in initiating retired pay. Any collection of information as defined in the Paperwork Reduction Act of 1995 codified at 44 U*S*C. 3501 et seq on this form has not been approved by the Director of the Office of Management and Budget OMB and does not display a valid control number assigned by the Director. Therefore no person shall be subject to any penalty for failing to comply with any such collection of information* SECTION I IDENTIFICATION AND ADDRESS complete all sections if not applicable enter N/A 1. YOUR APPROVED RETIREMENT DATE 2. Retiring from the following Service select one NOAA PHS Coast Guard Active Duty 4. Rank/Pay Grade 3. Name Last First MI. Coast Guard Reserve 5. Employee ID Number EMPLID 6. Date of Birth 8. Area Code Telephone Number Work 7. Correspondence Address Street City State and Zip Code Home Cell/Other 9. Please provide your Home Business if applicable email addresses if you would you like PPC RAS to contact you via e-mail in case telephone contact cannot be established H B 10. Do you want your contact information email and phone number released to the National/Regional Retiree Council* See instructions for further information* Yes No SECTION II PAY DELIVERY See instructions for proper completion Public Law 103-356 makes direct deposit mandatory Continue direct deposit to the same account used for your active duty/reserve pay. Attach an LES or DA view paycheck page print* New direct deposit account shown below or for new direct deposit accounts attach a voided check. 13. Type of Account Checking Savings 14. Routing Transit Number RTN 15. Account Number 16. Financial Institution Name 17.
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