2378 DoD Authorization for Purchase and Request for Change U.

DEPARTMENT OF DEFENSE
Authorization Form SB-2378
OMB No. 1535-0111

RESET

1. BRANCH OF SERVICE

AUTHORIZATION FOR PURCHASE AND REQUEST FOR CHANGE
UNITED STATES SERIES EE SAVINGS BONDS OR
UNITED STATES SERIES I (INFLATION-INDEXED) SAVINGS BONDS
2. SOCIAL SECURITY NUMBER

4. NAME

5. DEPT/AGENCY/DUTY STATION

Select One Denomination

If you checked A, B, or C
above indicate amount
to be allotted each pay
period.

$75

(Active Duty Only)

$100

$200

F Other Action

(Describe below)

$500

$1000

Chart below determines number of pay periods needed to purchase each Bond. (Pay periods per year: Military 12 — Civilian 26).

Face Value $50

Face Value $75

I - Costs $50
I
Deduction
$5.00
10
$6.25
8
$10.00
5
$12.50
4
$25.00
2
$50.00
1

I - Costs $75
I
Deduction
$7.50
10
$12.50
6
$25.00
3
$75.00
1

I BOND
OR

$50

E Safekeeping

Inscription

OTHER ACTION

Select One Series Per Card

EE BOND

I only

6. DUTY PHONE NO.

D Change

Denomination

Allotment

Allotment

For allotment options, see
your campaign volunteer
or payroll office.

C Change

B Increase

A New

REQUESTED ACTION

PRINT IN INK OR TYPE

3. PAY GRADE (Military Only)

$

Face Value $100
EE - Costs $50
I - Costs $100
Deduction
EE/I
$5.00
10/NA
$6.25
8/NA
$10.00
5/10
$12.50
4/8
$20.00
NA/5
$25.00
2/4
$50.00
1/2
$100.00
NA/1

Face Value $200
EE - Costs $100
I - Costs $200
Deduction
EE/I
$10.00
10/NA
$12.50
8/NA
$20.00
5/10
$25.00
4/8
$50.00
2/4
$100.00
1/2
$200.00
NA/1

Face Value $500
EE - Costs $250
I - Costs $500
Deduction
EE/I
$25.00
10/NA
$31.25
8/NA
$50.00
5/10
$62.50
4/8
$100.00
NA/5
$125.00
2/4
$250.00
1/2
$500.00
NA/1

Face Value $1,000
EE - Costs $500
I - Costs $1,000
Deduction
EE/I
$50.00
10/NA
$62.50
8/NA
$100.00
5/10
$125.00
4/8
$200.00 NA/5
$250.00
2/4
$500.00
1/2
$1000.00 NA/1

BOND INSCRIPTION Complete the following if (a) you checked A or D on reverse; or (b) you have multiple Bond allotments
9. Social Security Number (Required)

8. Bond Owner’s Name

7. Effective first payroll period after
a. Number and Street
10. Address

b. City or Town

11. Check one if you wish to
designate a co-owner or beneficiary
BENEFICIARY
CO-OWNER

c. State
12. Name (First Name)

(Middle Name or Initial)

a. Name (First Name)
14. Mail Bond To:
(If different from above)

b. Number and Street

d. ZIP Code
(Last Name)

(Middle Name or Initial)
c. City or Town

13. Social Security Number (Optional)

(Last Name)
d. State

e. ZIP Code

(Return signed form to your payroll
office or campaign volunteer)
I hereby authorize the foregoing allotment from my pay for the purchase of U.S. Savings Bonds to be issued with the inscription shown on this form.
EMPLOYEE’S SIGNATURE

This Authorization is to remain in effect until cancelled by me in writing or termination of my employment.
Married women should use their given names, e.g., “Mary L. Smith”. If coowner or beneficiary is designated, the inclusion of that individual’s Social Security number is
desireable but not required. The use of courtesy titles is optional.

NOTICE UNDER THE PRIVACY AND PAPERWORK REDUCTION ACTS
The Treasury Department’s Bureau of the Public Debt keeps records about who owns savings bonds. Please fill in the information that applies to you so that we can issue
savings bonds and keep accurate records as authorized by Title 31 of the United States Code, Chapter 31. We don’t disclose any information except as authorized by law.
We estimate it will take you about one minute to complete this form. However, you are not required to provide information requested unless a valid OMB control number is displayed
on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328.