Transfer Information Sheet Form – Fill Out and Use This PDF

		Date:
TRANSFER INFORMATION SHEET
Rate:	Name:	SSN:

Command:

A. INDIVIDUAL CONCERNED COMPLETE SECTION “A” OF THIS FORM AND DELIVER TO YOUR DIVISION OFFICER

Work Phone:		Home Phone:				E-mail Address:
Primary Next Of Kin:								Secondary Next Of Kin:
Name and Relationship:							Name and Relationship:
Address:							Address:
Telephone (including Area Code):							Telephone (including Area Code):
Requested Transfer Date:
Requesting Leave	Leave Address and Phone Number:
(No. of Days):
Incur Obligated Service by:				Advance Pay Desired:					Advance DLA Desired:
Extension Reenlistment				Yes (Complete attached form)					Yes No (married pers. &
Page 13 (if approved)				No					single E7 & above only)
Will your dependents				Are you using your COT				Home of Record: (CITY, STATE)
accompany you on transfer?				entitlement? (if applicable)
Yes No				Yes	No Not Eligible
Will TLA Claim be submitted:			Yes No (COMPLETE TLA PACKAGE, MUST BE TURNED IN PRIOR TO
MEMBER’S DEPARTURE)

Final PSD Pearl Out Process Appointment will be arranged by CPC/Leading Yeoman to be scheduled within five (5) days prior to transfer date.

Signature of Member:	Date:

B. DIVISION OFFICER complete Section “B” and check the box if task has been completed

Indicate Member’s Transfer Date if other than requested:

Inform individual that transfer departure date will not be changed once it is determined except for emergency reasons, as orders and records will be processed upon return of this form to the Transfers Section.

Transfer Information Sheet and required enclosures have been reviewed and verified. PACKAGE MUST BE COMPLETED WITHIN 30 DAYS OF RECEIPT OF ORDERS.

Copy of PCS Orders	Request for Advance PCS/TDY Travel Request
Passenger Reservation Request 4650/5	Temporary Lodging Allowance (TLA)
Application For Transportation of Dependents	Information Sheet and Worksheet
Family Entry Approval (FEA) Worksheet Req.
Advance Pay Certification/Authorization	Other: ______________________________
Required obligated service: has been completed or		will be completed on _______________

Required screening(s) has/have been completed. Copies attached.

Transfer Evaluation (E6 and below)/FITREP (E7-E9 only) will be forwarded to PERS 311.

CPC/Leading Yeoman informed to make Final PSD out-processing arrangements.

Inform member to pick up Medical and Dental records if member is transferring off island.

I certify that I have taken or initiated action on all items listed in Section “B”.	Date:
Signature of Division Officer:
C. APPROVING AUTHORITY FOR COMMAND complete Section “C”

PRIVACY ACT STATEMENT

The information requested on this form is to provide a means of making Permanent Change of Station (PCS) arrangements. This form is used as a guide for processing for an accurate transfer and remains part of the retain file. Disclosure of requested information is voluntary; however completion of this form is necessary before the Transfer can be processed. Failure to provide any of the requested information may result in Transfer not being processed.

***** THIS FORM MUST BE TYPED *****

1. MEMBER’S NAME (LAST, FIRST, M.I.)

2. RANK/RATE

3. SSN

4. COMMAND

5. DETACH DATE

NAME ENTERED MUST MATCH NAME ON

2A.GENDER

3A. DOB

VALID PHOTO I.D. CARD

6. CPC/TRAVEL COORDINATOR

7. PHONE

8. EMAIL

9. MEMBER’S LOCAL PHONE:

10. EMAIL ADDRESS-WORK

11. EMAIL ADDRESS-HOME

AREA CODE:

PHONE NUMBER:

12. MEMBER’S TRAVEL (INCLUDING LEAVE STOPS, WHICH MEMBER

WILL PAY FOR, IF APPLICABLE)

DATE FROM

TO

13. FAMILY MEMBER(s) TRAVEL

****NAME(S) ENTERED ON DD-884 MUST MATCH NAMES ON VALID PHOTO I.D. CARD*****

TRAVELING WITH SPONSOR OR…

TRANSPORTATION REQUESTED AS FOLLOWS:

DATE FROM

TO

GENDER DOB

SSN

NO-FEE PASSPORT # ISSUE DATE NON US CITIZEN

14. TYPE SEAT REQUESTED

15. FLIGHT TIME REQUEST

WINDOW

0700 - 1200

AISLE

1200 - 1800

1800 - 2400

16. PRIVATELY OWNED VEHICLE (POV)

17. LEAVE INFORMATION

NOT SHIPPING A POV

ADDRESS:

CITY/STATE:

SHIPPING PRIMARY POV TO:

AREA CODE:

PHONE NUMBER:

17a. EMERGENCY CONTACT:

NAME:

AREA CODE:

PHONE NUMBER:

NOTE: AMC LIMITS 2 PETS, CATS OR DOGS ONLY, WITH MAXIMUM WEIGHT (PET & KENNEL) OF 100 POUNDS EACH. OTHER:

19. REMARKS

NOTE:

PLAN YOUR TRIP CAREFULLY BEFORE SUBMISSION OF THIS REQUEST. CHANGES TO CONFIRMED FLIGHTS MAY BE MADE ONLY AS A RESULT OF ORDER MODIFICATION OR DUE TO MISSION REQUIREMENTS.

PRIVACY ACT STATEMENT: THE INFORMATION REQUESTED ON THIS FORM IS PROTECTED UNDER AUTHORITY OF T U.S.C. 552a AND THE JOINT TRAVEL REGULATIONS TO PROVIDE A MEANS OF MAKING PERMANENT CHANGE OF STATION (PCS) TRAVEL ARRANGEMENTS. THE FORM IS USED AS A GUIDE FOR PREPARING AN ACCURATE TRAVEL ITINERARY AND REMAINS PART OF THE RETAIN FILE. DISCLOSURE OF REQUESTED INFORMATION IS VOLUNTARY, HOWEVER COMPLETION OF THIS FORM IS NECESSARY BEFORE TRANSPORTATION CAN BE AUTHORIZED. FAILURE TO PROVIDE ANY OF THE REQUESTED INFORMATION MAY RESULT IN DISAPPROVAL OF TRAVEL REQUEST.

______________________________________________________________					___________________________
20. MEMBER’S SIGNATURE					21. DATE
		PSD/PERSONNEL OFFICE USE ONLY
22. PCS ORDERS		23. SIGNED DD 884				24. OVERSEAS SCREENING COMPLETED:
ATTACHED		ATTACHED		NOT APPLICABLE		YES	IN PROGRESS		NOT APPLICABLE
25. PASSPORT REQUIREMENTS:		26. AUTHORIZED TO TRAVEL VIA NEW				27. DEPENDENT ENTRY REQUIRED
DD1056 COMPLETED/ISSUED		HOMEPORT OF SHIP (U5120.F3)				YES		APPROVED	PENDING
		YES NO		NOT APPLICABLE		IF PENDING, DTG OF FEA MSG REQUEST
28. HOR TRAVEL				29. TYPE TRAVEL
ENTITLED	DEFERRED			ACCOMPANIED	UNACCOMPANIED			PCS	COT
NOT ENTITLED				DEFERRED COT	OTEIPO		SEPARATION/RETIREMENTS
30. NAME OF SUBMITTING CLERK				31. EMAIL ADDRESS
32. DATE				33. SIGNATURE
				________________________________________________________________

PSDPH Form 4650 (Rev 01/11)

THE PRIVACY ACT OF 1974. AUTHORITY: 37 U.S.C. 406 (Military); 5 U.S.C. 5724 (Civilian). THE PRINCIPAL PURPOSE:

Application for transportation-in-kind of dependents with CONUS used as an authority to issue transportation requests in absence of dependent travel orders. ROUTINE USES: Used in lieu of dependent travel orders by transportation offices to issue transportation requests within CONUS. VOLUNTARY: However, if information is not furnished, transportation would not be furnished.

SHIP OR STATION

*If other than a lawful spouse or unmarried legitimate child under 21 years of age of a member, complete applicable certificates below.

PRESENT ADDRESS OF DEPENDENTS (Street Address, City, State and ZIP Code)

OLD PERMANENT STATION		NEW PERMANENT STATION		DATE OF ORDERS (YYMMDD)
TRANSPORTATION REQUESTED (FROM) (City, State)		(TO) (City, State)		(VIA) (ROUTE) (City, State)
DATE OF DEPARTURE (YYMMDD)	BY (Air, Rail, etc.)	FOR TRAVEL OUTSIDE THE U.S., IS GOVERNMENT		AIR TRANSPORTATION
		ACCEPTABLE FOR YOUR DEPENDENTS?	YES		NO

**If travel is from other than vicinity of old station or to other than vicinity of new station, state reasons; if orders were received during temporary absence of dependents from old duty station, explain necessity for their return thereto prior to proceeding to new station.

I CERTIFY THAT TRANSPORTATION FOR PERSONS LISTED ABOVE, WHO WERE MY DEPENDENTS ON THE EFFECTIVE DATE OF APPLICABLE ORDERS, IS BEING REQUESTED WITH THE INTENT OF ESTABLISHING A BONA-FIDE RESIDENCE. I FURTHER CERTIFY THAT I HAVE NOT MADE APPLICATION OR SUBMITTED CLAIM FOR TRANSPORTATION OF MY DEPENDENTS ON THIS CHANGE OF STATION EXCEPT AS FOLLOWS:

		(Required for dependent parents, adopted children, stepchildren and for mentally
	I	or physically incapacitated children over 21 years of age.)
		I CERTIFY THAT MY DEPENDENT(S) (Relationship)				, NAMED ABOVE,
	CERTIFICATE	IS/ARE IN FACT DEPENDENT UPON ME AND THAT A CERTIFICATE OF DEPENDENCY WAS APPROVED BY THE
	OF PROOF OF	APPROPRIATE AGENCY, I FURTHER CERTIFY THAT THERE HAS BEEN NO CHANGE IN THE CONDITIONS OF
	DEPENDENCY	DEPENDENCY SINCE THE CERTIFICATE WAS APPROVED.
		(NOTE: In the case of a dependent parent, the certificate of dependency must be approved annually.)
	II	(Required for a dependent parent in addition to I.)
	CERTIFICATE	I CERTIFY THAT MY DEPENDENT(S) (Relationship)					,
	OF RESIDENCE	IS/ARE RESIDING AS A MEMBER OF MY HOUSEHOLD AND WILL RESIDE AS A MEMBER OF MY HOUSEHOLD
	OF PARENT	ESTABLISHED INCIDENT TO THIS CHANGE OF STATION.
		(Required for a step child in addition to I.)
	III
	CERTIFICATE	I CERTIFY THAT (Name of child’s other parent)					,
	FOR STEPCHILD	THE MOTHER/FATHER OF THE STEPCHILD/STEPCHILDREN NAMED ABOVE, WAS MY LEGAL SPOUSE ON THE
		EFFECTIVE DATE OF APPLICABLE ORDERS.
	DATE (YYMMDD)	SIGNATURE OF APPLICANT

DD FORM 884, NOV 80 (EG)

SUPERSEDES ALL PREVIOUS EDITIONS.

Designed using Perform Pro, WHS/DIOR, Oct 94

ADVANCE PAY CERTIFICATION/AUTHORIZATION

PART I - PURPOSE

The purpose of an advance of pay incident to a PCS is to provide a service member with funds to meet the extraordinary expenses of a Government-ordered relocation.

An advance of pay shall not be authorized for the specific out-of-pocket expenses covered by advances of other pays and entitlements if such advances are used. The service member may be authorized an advance of pay to the extent that incurred or anticipated expenses exceed those covered by the following advances or reimbursements, or are outside of the scope of those entitlements:

An advance of pay for a PCS move in the same geographic area of a service member’s prior duty station, home port, or place from which ordered to active duty, is only authorized when the service member moves his/her household effects at Government expense. Proof of HHG shipment is required before advance pay for PCS moves in the same geographic area is paid.

An advance of pay is not intended to provide funds for such items as investments, vacations or the purchase of consumer goods that are not the result of direct expenses resulting from the service member’s PCS orders.

PART II – MEMBER CERTIFICATION

PENALTY: The penalty for willfully making a false claim/statement is: A MAXIMUM FINE OF $10,000.00 OR MAXIMUM IMPRISONMENT OF FIVE YEARS, OR BOTH (U.S. Code, Title 18, Section 287.)

I have read and understand the Navy’s policy on advance pay incident to a PCS. I hereby certify that the intended use of these funds is in accordance with the stated purpose.

d. SIGNATURE

PART III – REQUEST

PART IV – CERTIFICATION OF EXPENSES (Attach extra sheets if necessary.)

EXPENSE (actual or anticipated)
a.	$	d.	$
b.	$	e.	$
c.	$	f.	$

EXPLAIN CIRCUMSTANCES WHERE GREATER THAN NORMAL EXPENSES MIGHT BE INCURRED OR CIRCUMSTANCES REQUIRING AN EARLY OR LATE PAYMENT OF ADVANCE PAY

PSD P!:ARI. HARBOR HI ADVANCE PCSrTDY TRAVEL REQUEST

Name: ____________ Rank/Rale:	SSN: ---- , --

Currenl Duly Slation: ________________ Dale reported: _____

Ne"muly Slalion: ________________ Date detaching: ____

o Temporary Duty Per Diem at Next Intennediate Duty Station

Where v.111 you reside? 0 BEQ/BOQ 0 Ott-base (CNA) required) CNA # _ _ _______

Daily cost of lodging: $__ For period _______ through _______

o Service Member pes Entitlements

Traveling from ="";.,.,-_,,.---....,-_10 ="""",,--;-_-,,--,.-:-_

(City/State or Country) (CIIy/Stale or Country)

How do you plan 10 travel? 0 POV from _--,-___--10 _____- . _

o Govt-procured Air (GTR) 0 Other: __-'-____
Do you desire Advance ｄｩｳｬｯｾｴｩｯｮ＠Allowance COLA)? 0 Yes ('YVlth Dependents)	0	No Advance desired
Single E7 and above 0 Yes (Single) 0 No Advance desired

I hereby request advance payment of dislocation allowance due to my transfer on

. I certify that It Is

my intention not to occupy Government quartel'$ permanently upon arrival at my new permanent duty station. If I am

permanently assigned Govemment quarters, I understand.I wfll be required .to repay the advance dislocation allowance.

Note: Do not pay Advance DLA for Single £6 ana below without a statement from the gaining CQmmana tha t the member is not required to use government quarters. DODFMR Vol 9 para 0606.

oFamily Member pes Entitlements

WlU your dependent(s) be traveling with you? 0 Yes 0 No

When v.111 your dependent(s) travel? =--,..,-.,.,.,-_ through ===:-7=

(Start dale)	(Completion dale)
Where: will your dependent(s) travel from?	to ""=====:::;-

(City/stale or Country) (City/State or Country)

How does/do your dependent(s) plan ,to travel?

0

POV 0 GTR NumbElr of POVs to be used: __

Clty/StalelZlp: ________-'--__

Signature/date:,__________

PSDPH 7220/1 November 2006

PRIVACY ACT STATEMENT: The info.rmation requested on this form is required under the provision of3l U.S.C. 82b and 82e, for the purpose of disbursing Federal money. "The information requested is to identify the particular creditor and the al110unts to be paid . Failure to furnish this information will hinder discharge of the payment obligation.

TEMPORARY LODGING ALLOWANCE (TLA) WORKSHEET

FAMILY MEMBERS ON STATION

FOR ARRIVAL TLA:

DATE MEMBER REPORTED TO PRESENT COMMAND: _________________________

DATE FAMILY MEMBER(S) REPORTED TO PRESENT COMMAND: _________________________

THIS IS THE ______ CLAIM

MEMBER MUST PRESENT TLA AUTHORIZATION FROM THE HOUSING OFFICE AND A PAID LODGING RECEIPT. A FAMILY MEMBER WHO IS FILING TLA DUE TO THE ABSENCE OF THE SPONSOR MUST HAVE A GENERAL OR SPECIAL POWER OF ATTORNEY SPECIFICALLY STATING TLA IS AUTHORIZED FOR PROCESSING.

FOR DEPARTURE TLA:

ACTUAL DATE OF DETACHMENT: _________________________

MEMBERS LIVING OFF-BASE MUST PRESENT A RENTAL RELEASE FROM THE LANDLORD OR REALTOR.

MEMBER LIVING ON-BASE MUST PRESENT A SIGNED STATEMENT FROM THE HOUSING OFFICE CERTIFYING THE DATE GOVERNMENT QUARTERS WERE VACATED.

MEMBER’S STATEMENT:

I HAVE INCLUDED HEREIN ALL LODGING RECEIPTS FOR TLA. I CERTIFY THAT I AM / AM NOT IN A PER DIEM STATUS. I UNDERSTAND

THAT IF I AM IN A TEMPORARY DUTY PER DIEM STATUS, ONLY MY FAMILY MEMBERS ARE ENTITLED TO TLA. I FURTHER CERTIFY THAT MY FAMILY MEMBERS AND I DID / DID NOT UTILIZE GOVERNMENT MESS FOR ANY MEALS DURING THIS PERIOD. MY TEMPORARY QUARTERS DO / DO NOT CONTAIN FACILITIES FOR PREPARING AND CONSUMING MEALS.

WARNING:

THE PENALTY FOR WILLFULLY MAKING FALSE CLAIM IS: MAXIMUM FINE OF $10,000.00 OR MAXIMUM IMPRISONMENT FOR FIVE YEARS, OR BOTH (U.S. CODE, TITLE 18, SECTION 287). BE ADVISED THAT ALL CLAIMS ARE SCREENED AND THOSE SUSPECTED OF BEING FRAUDULENT ARE TURNED OVER TO THE NAVAL CRIMINAL INVESTIGATIVE SERVICE (NCIS).

PRIVACY ACT STATEMENT:

THIS STATEMENT IS PROVIDED IN COMPLIANCE WITH THE PROVISIONS OF THE PRIVACY ACT OF 1974 (PL 93-579) WHICH REQUIRES THAT FEDERAL AGENCIES MUST INFORM INDIVIDUALS WHO ARE REQUESTED TO FURNISH INFORMATION ABOUT THEMSELVES AS TO THE FOLLOWING FACTS CONCERNING THE INFORMATION REQUESTED.

1.AUTHORITY: 37 USC 1006

2.PRINCIPAL PURPOSE: TO PROVIDE INFORMATION REQUIRED TO LEGALLY PAY TEMPORARY LODGING ALLOWANCE (TLA).

3.ROUTINE USE: THE MEMBER PROVIDES INFORMATION ON COST AND TYPE OF LODGING WHICH IS USED TO COMPUTE ENTITLEMENT TO TLA. SUPPORTING DOCUMENTS ARE USED TO DETERMINE ELIGIBILITY AND AMOUNT OF ENTITLEMENT.

4.MANDATORY OR VOLUNTARY DISCLOSURE: VOLUNTARY. IF MEMBER DOES NOT PROVIDE INFORMATION, TLA CANNOT BE PAID.

PSAFE 7220/4 (Rev. 10-97) (FRONT)