VCS Deduction Form – Fill Out and Use This PDF

Privacy Act Notice: The following information is provided to comply with the Privacy Act of 1974 (PL 93-579). The information collected on this form will be used by VCS to identify you as an authorized VA employee customer eligible to participate in the Payroll Deduction Program (PDP); to establish a PDP account on your behalf; and to the administer PDP account transactions. Executive Order 9397 authorizes collection of your Social Security Number. Information collected may be disclosed to an authorized VCS/VA employee responsible for administering and recording purchase and payment transactions to your PDP account. It may also be disclosed to representatives of the U.S. Treasury Offset Payment System (TOPS); to authorized 3rd party debt collection agents; or to agents of any other authorized debt collection service for the purpose of collecting unpaid and /or past due balances for customers no longer employed by the VA. Disclosing of requested information is voluntary; however, failure to provide the information will prevent your participation in the PDP.

AGREEMENT

1– The following constitutes the Agreement between you, the customer, and the VCS regarding your participation in the VCS Payroll Deduction Program (PDP), Completion of Agreement is a condition for using the PDP for purchases in VCS stores, food courts and other identified activities. By your signature below, you agree to the following terms:

A– I will provide my VA Employee ID badge as the sole means of personal identification when making purchases.

B - PDP payments will be deducted from my pay on a bi-weekly basis as long as there is a positive balance to my account. The amount of the bi-weekly deduction will be based on my account balance on the last day of each pay period. The payment schedule is as follows:

Balance	Divided By =	Pay Period Deduction
$ .01 to $25	1
$ 25.01 to $50	2
$ 50.01 to $75	3
$ 75.01 to $500	4
$500.01 to $600	5
$600.01 to $750	6
$750.01 to $875	7
$875.01 to $1350	8	(payment not to exceed $125)

C - In the event of the discontinuance of my employment with the VA, I hereby voluntarily consent to any balance still owed to the VCS being deducted from my final salary payment, annual leave payment.

D– If my payroll deduction account is not paid in full when I leave VA employment, I also voluntarily consent to the disclosure of any employment or PDP information permitted by law and necessary to collect the debt I owe VCS. Information may be disclosed to agents of TOPS, 3rd,party collection, or any other collection service/method authorized by law. Information disclosed may include: Social Security Number, amount of unpaid account balances, current or former addresses, telephone numbers, names of financial institutions and accounts, and related personal locator/identifier information.

II– I have read and understand the above Agreement. I fully understand that personal identifying information of the nature described above may be disclosed to collect a valid debt. I expressly agree to the cited terms and conditions of this Agreement.

Customer Signature:_______________________________________________
_______________________________________________	________________________________________
VCS Authorizing Official Signature/Date	VA Payroll Verified Eligible By/Date

**Applicant should receive a copy of agreement upon signature.

**One copy should be retained in Canteen Office in locked cabinet until EPD card is web activated. This form should be shredded upon confirmation of activation.