Phs 6134 Form PDF Details

The PHS-6134 form is an essential document required by the Department of Health and Human Services, namely within the Public Health Service Division of Commissioned Corps Assignments under the Office of Commissioned Corps Operations and the Office of the Surgeon General. Situated in Rockville, MD, the form serves a pivotal role in determining an officer's retirement and base pay credit. It meticulously tracks the officer's service, capturing both active and inactive periods, including initial appointments, subsequent active duty or training stints, and any discharges, to accurately calculate entitlements. Importally, individuals are prohibited from self-completing the PHS-6134; it necessitates authentication by an official holding custody of the officer's personnel records. For those on active duty, submission is directed to their current file manager, whereas former service members or those in the inactive reserve are instructed to forward this document to the Military Personnel Record Center. Multiple submissions may be required for officers with disconnected service tours, ensuring comprehensive coverage of their service history. Furthermore, the form's completion plays a critical role in adhering to the Privacy Act of 1974, with the collected information explicitly used to establish service dates for various pay and retirement credits, also stipulating the mandatory disclosure of an officer's Social Security Number for identification and administrative purposes. The guidelines emphasize the importance of this form in verifying entitlements, illustrating its significance within the wider context of military personnel management and benefits entitlement.

QuestionAnswer
Form NamePhs 6134 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesWootton, PSC, phs 6134, seq

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Division of Commissioned Corp Assignments

Office of Commissioned Corps Operations

Office of the Surgeon General

1101 Wootton Parkway, Plaza Level, Suite 100

Rockville, MD 20852

Re: Information Regarding Completion of Form PHS-6134 Statement of Service

The PHS-6134 (Statement of Service) must be completed and certified by the official maintaining your official personnel folder containing your military records. You may not complete your own PHS-6134.

This form is used for calculating the retirement and base pay credit for an officer and must include the initial appointment date and all subsequent dates of active and inactive service. It must also include any applicable dates of discharge.

If you are currently on active duty, you should submit this form to the official currently in charge of your active duty file. If you are in the inactive reserve, or have separated entirely from the military, you must submit this form to the Military Personnel Record center at the address below. If you have a prior tour and a current tour of active duty, you MAY have to submit a copy of this form to each location.

This form must be authenticated. For prior service, send to:

GENERAL SERVICES ADMINISTRATION

National Personnel Records Center

(Military Personnel Records)

9700 Page Boulevard

St. Louis, Missouri 63132

DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. PUBLIC HEALTH SERVICE COMMISSIONED CORPS

STATEMENT OF UNIFORMED SERVICE OTHER THAN U.S. PUBLIC HEALTH SERVICE COMMISSIONED CORPS

Creditable Under 10 U.S.C. 1208 and 37 U.S.C. 205

OFFICER’S NAME (Please PRINT or TYPE)

 

LAST

FIRST

MIDDLE NAME

SOCIAL SECURITY NO.

SERVICE NUMBER(S)

NATURE OF ACTION

(For Officers, enter COMM or WO Component)

(For Enlisted, enter ENL and Component)

EFFECTIVE DATES

(For Officers, enter Date of Acceptance) (For National Guard, enter Dates of Federal Recognition)

ACTIVE DUTY OR

ACTIVE DUTY FOR TRAINING

From

To

 

 

SEPARATION

(Indicate Type and Reason)

DAYS

Number of days paid for Lump Sum Annual Leave after February 9, 1976 ............................................................................

YEARS

MONTHS

DAYS

Number of days of leave without pay (AWOL) ............................................................................

DATE

AUTHENTICATION

 

 

SIGNATURE

NAME (Type or Print)

TITLE

MAIL COMPLETED FORM TO:

Office of Commissioned Corps Operations Division of Commissioned Corps Assignments

ATTN: Gold Team - Application Support Attachments

1101 Wootton Parkway, Suite 100

Rockville, MD 20852

ISSUING OFFICE ADDRESS

ISSUING OFFICE PHONE NUMBER (

)

 

 

 

PHS-6134 (Rev. 10/04)

FRONT

PSC MEDIA ARTS EF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. PUBLIC HEALTH SERVICE COMMISSIONED CORPS

Privacy Act Notice for

STATEMENT OF UNIFORMED SERVICE OTHER THAN U.S. PUBLIC HEALTH SERVICE COMMISSIONED CORPS (Form PHS-6134)

Records System: 09-40-0001, "PHS Commissioned Corps General Personnel Records," HHS/PSC/HRS.

General: This statement is provided pursuant to the Privacy Act of 1974 (P.L. 93-579).

Authority for Collection of Information: 42 U.S.C.; 202 et seq. Executive Order No. 10450

Purposes and Routine Uses: The principal purpose of the information provided on this form is to establish service credit dates for base pay, special pay, incentive pay, and retirement credit. These records may be disclosed to substantiate pay, allowances, and eligibility for retirement; to other Federal agencies in the event of appointment of officers; to the Department of Housing and Urban Development and Department of Veterans Affairs in the event of employment claims and benefits; for study purposes and/or collection of statistical data; and for other lawful purposes including 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 Public Health Service (PHS) commissioned 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: Submission of this information is voluntary. However, failure to furnish this information may result in total or partial denial of creditable service in the Uniformed Service for pay and retirement benefits.

PHS-6134 (Rev. 10/04)

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