Form Cg Ppc 4700 – Fill Out and Use This PDF

Privacy Act Statement: This information is collected under 5 USC section 552a(e)(3), Public Law 92-425, 21 Sep 72: EO 9397. Information will be used to establish retired pay account and to enroll in the Survivor Benefit Plan. The information transmitted in this form is necessary and must be completed to establish the retired pay account.

Purpose: Provide an address for correspondence with Coast Guard Personnel Service Center

Designate your direct deposit account

Specify number of exemptions and marital status for Federal income tax withholding

Designate State and withholding amount for Voluntary State Tax withholding

Designate beneficiaries for unpaid retired pay.

Certify eligibility and entitlement to retired pay

Enroll in the Survivor Benefit Plan

Section I: IDENTIFICATION AND ADDRESS (complete all sections, if not applicable enter N/A)

6a. 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)____________________________________________

Section II: PAY DELIVERY (See instructions for proper completion and don’t forget to attach a voided check to your application.)

Public Law 103-356 makes direct deposit mandatory

7a.

[

] Continue direct deposit to the same account used for your active duty/reserve pay (attach current copy of LES).

7b.

[

] Direct deposit account shown below.

8.

Type of Account: [ ] Checking

[ ] Savings

9a.

Routing Transit Number (RTN)

Check Digit

9b.

Account Number

10.Financial Institution Name

11.Address-City, State, and ZIP Code

Section III: TAX WITHHOLDING INFORMATION (use instructions for IRS Form W-4 and State Tax form to complete)

	FEDERAL WITHHOLDING			VOLUNTARY STATE WITHHOLDING
	12.	Marital Status (check one): [ ] Single,	[ ] Married or	16. State designated to receive tax
		[ ] Married but withhold at higher single rate
				17. Requested Monthly Amount for State
	13.	Total No. of Exemptions Claimed		Tax (Whole dollar amount but not less	$
				$10.00)
	14.	Additional Withholding (optional)	$	Note: The State you designate to receive tax must have an
				agreement with the Department of Defense for withholding
	15.	“I claim exemption from withholding”		state tax. A listing of states that have agreements for
	Enter “EXEMPT”. If you claim EXEMPT			withholding is included with the instructions for this form.
	status, you must attach current year IRS			This election will remain in effect until changed by you.
	form W-4.
	(Page 1 of 4)			Previous editions are obsolete and shall not be used

FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT

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. I am aware that under the provisions of 10 U.S.C. 2771 and 4 CFR Part 34, this designation will remain in effect unless canceled or changed by me.

18a. Name (Last, First, Middle Initial)		18b. Relationship	18c. Address (City, State & ZIP Code)	18d. Telephone (Including Area Code)	18e. Share (Total
					must equal 100%)
1.
Social Security Number
2.
Social Security Number
3.
Social Security Number
4.
Social Security Number

Section V: CERTIFICATION DATA FOR PAYMENT OF RETIRED PERSONNEL (must be completed)

“I	[	]	have	[	] have not been convicted of any offense involving the National Security (5 U.S.C. 8312).
“I	[	]	have	[	] have not failed or refused to testify before a Federal Grand Jury, Court of the United States, courts-martial, or

congressional committee in connection with any matter endangering the National Security, or defense of the United States or any relationship I have or have not had with a foreign government (5 U.S.C. 8314).

“I	[	] have [	] have not knowingly or willfully remained outside of the United States or its territories or possessions to avoid
prosecution (5 U.S.C. 8313).
“I	[	] have [	] have not knowingly or willfully made a false, fictitious, or fraudulent statement or representation, or knowingly and

willfully concealed a material fact in an employment application for a civilian or military office or position in or under the Legislative, Executive, or the Judicial branch of Government of the United States or the government of the District of Columbia(5 U.S.C. 8315).

“I [ ] am [ ] am not employed by any foreign government, company, educational institution, or other concern which is controlled in whole or in part by a foreign government nor have I made application for such employment and I have not negotiated for such employment. I understand that before I accept such employment I must obtain advance approval from Commandant (CG-1222) and the Department of State.

I [ ] am [ ] am not drawing a pension, retired pay, or disability compensation from the Department of Veterans Affairs (VA), Civil Service Commission, or other Government agency nor have I made application for such benefits.

If you are drawing a VA or civil service pension, retired pay, or disability compensation, or have made application therefore, please provide the name and address of the agency and the monthly amount received (if any) in the space below.

Page 2 of 4. FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT

Section VI: SURVIVOR BENEFIT PLAN (SBP) ELECTION (Complete all blocks)

21. FOR Reserve Retiree Only – Have you elected RCSBP (option B or C) prior to this date

Yes No

IF YES, ATTACH A COPY OF THE ELECTION FORM and skip to Section VIII

IF NO or elected (option A), complete the remainder of Section VI & VII

22.Beneficiary Category (ies)

a I elect coverage for spouse only. I do do not have dependent children. b I elect coverage for spouse and child(ren).

c I elect coverage for child(ren) only. I do do not have a spouse.

d I elect coverage for the person named in block 45 who has an insurable interest in me.

e I elect coverage for the person named in block 39 who is my former spouse.

f I elect coverage for the person named in block 39 who is my former spouse and dependent child(ren) of that marriage g I elect not to participate in SBP. (Blocks 24-27 must be completed even if no coverage elected)

23.Level of coverage (do not complete if 22d or 22g was elected above)

aI did NOT elect the Career Status Bonus and REDUX. I elect SBP coverage as follows (choose one):

I elect coverage based on full gross retired pay.

I elect coverage with a reduced base amount of $________ ($300 minimum base amount).

bI DID elect the Career Status Bonus and REDUX. I elect SBP coverage as follows (choose one):

I elect coverage based on the amount of retired pay I would have received had I NOT elected the Career Status Bonus. I elect coverage based on my current gross retired pay.

I understand this represents a reduced base amount and requires spousal concurrence.

I elect coverage with a reduced base amount of $________ ($300 minimum base amount). This requires spousal concurrence.

24.	Spouse Name (Last, First, MI.)	25. Spouse SSN	26. Spouse Date of Birth
27.	Date of Marriage:

List your dependent child(ren) (Designate which children resulted from marriage to former spouse, if any)

28. Name (Last , First, Middle Initial.)

29. Relationship

30. Date of Birth

31. SSN

32. *Disabled Child

a.

Yes No

b.

Yes No

c.

Yes No

d.

Yes No

*BLOCK 32 NOTE: Disabled Child – If yes, provide a current physician's statement dated within 90 days of the date of retirement describing the medical condition and whether it is temporary or permanent and why the condition is considered incapacitating (e.g. the dependent is unable to take care of basic activities of daily living).

Section VII: SBP SPOUSAL CONCURRENCE (Required when member is married and elects child(ren) only coverage, does not elect full spouse coverage, or declines coverage)

I hereby concur with the Survivor Benefit Plan election made by my spouse. I have received information that explains the options available and the effects of those options. I know that retired pay stops on the date the retiree dies. I have signed this statement of my free will.

33. Spouse Signature: ___________________________________________________	38. NOTARY SEAL HERE

34.Subscribed and Sworn to before me in County ______________ State ________

35.On Month_________________ Day___________, 20______

36.My Commission expires the___________ day ____________,20________

37.Notary Public (Signature) ___________________________________________

Page 3 of 4. FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT

Former Spouse (Complete ONLY if 22e or 22f was elected above)

Insurable Interest (Complete ONLY if 22d was elected above)

Note: Under the law, you “first became a member” of the Uniformed Services on the date first enlisted, inducted, or appointed. For non-prior service Academy cadets and OCS graduates, it is the date you took the oath of office for entrance into the Academy (for Academy cadets, this is not the date your creditable service for retirement begins) or OCS. For enlisted members who enlisted under the Delayed Entry Program (DEP), it is the date you signed up for the DEP.

52. PRIOR SERVICE BREAKDOWN (FOR COAST GUARD ACTIVE DUTY OR NOAA PERSONNEL ONLY)

IF ANY OF THE ABOVE SERVICE WAS IN A RESERVE COMPONENT:

53.	Have you ever held a Rank/Rate higher than your current one?		If yes, what rank did you	When did you hold this rank?
	Yes	No	hold?
54.	Have you ever received severance, separation or readjustment pay from a		If yes, what amount did you	When did you receive such
	military service in connection with separation or release from active duty?		receive?	payment?

Yes No

Section IX: MEMBER’S CERTIFICATION (member and witness signature and date (must sign on same date) required for start of retired pay)

Under penalties of perjury, I certify that the number of withholding exemptions claimed does not exceed the number to which I am entitled, and that all statements on this form are made with full knowledge of the penalties for making false statements. (18 U.S.C. 287 and 1001 provide for a penalty of not more than $10,000 fine, or 5 years in prison, or both). Also, I have been counseled that I can terminate SBP participation, with my spouse's written concurrence, within one year after the second anniversary of commencement of retired pay. However, if I exercise my option to terminate SBP, future participation is barred.

55.	Member’ Name (last, first, middle initial)			56.	Member’s Employee ID Number:
57.	Member’ Signature			58.	Date
59. Witness Name (Last, First, MI) (over 18 years old & not a member of your family)		60.	Witness Signature
61.	Witness Address (Street, City, State and Zip Code	62.	Witness telephone number	63.	Date

Page 4 of 4. FOR ANY CORRECTIONS/CHANGES A NEW FORM MUST BE COMPLETED PRIOR TO DATE OF RETIREMENT