Monthly allotment from your retirement pay

Sponsor Identification

* Enter the 9-digit sponsor Social Security Number (SSN) or the TRICARE ID 11-digit DOD Benefits Number (DBN). * Sponsor First Name * Sponsor Last Name * Sponsor Date of Birth

Confirming Allotment Set Up

By checking the box on this form, I certify the information provided is true, accurate and complete. Federal funds are involved in this program and any false claims, statements, comments, or concealment of a material fact may be subject to fine and/or imprisonment under applicable Federal law.

NOTE: Only retired Uniformed Services members may establish an allotment from their retired pay. The Uniformed Service member must sign below. Your Regional Contractor (Martin's Point) will charge the correct fee amount each month based on your enrollment, individual or family. (The current rates are at http://www.tricare.mil/costs)

My submission of this form authorizes the Regional Contractor (Martin's Point) to CHANGE my automated payments as indicated below for myself and applicable beneficiaries. Fee amounts, as determined by TRICARE and subject to change each fiscal year, will be withdrawn between the first and the fifth business day of the month. This authorization will remain in force unless cancelled by me, my Regional Contractor (Martin's Point) or my financial institution.

* I choose to have my enrollment fees paid by monthly allotment from my Uniformed Services retired pay. * Name of Authorizing Sponsor, Spouse, or Other Legal Guardian of Beneficiary * Relationship to Sponsor * Today's Date