Free VA Form VAF-1100 - Agreement to Pay Indebtedness - Federal

AGREEMENT TO PAY INDEBTEDNESS
VA FILE NO. (Include letter prefix, if any) PAYEE NO. (If known) PERSON ENTITLED RECEIVABLE CODE

1. I,
(Name of Debtor)

, hereby acknowledge my
(Type of Debt)

indebtedness to the Department of Veterans Affairs in the amount of $

, which consists of

principal, interest and other costs accrued as of this date, as a result of my participation in a benefits program administered by the Department of Veterans Affairs. A. Complete only if repayment will be made by monthly payments to VA Agent Cashier. I promise to repay the Department of Veterans Affairs by paying minimum monthly payments of not less than $ , on or before the day of each month beginning
.

I agree to mail monthly payment to the Agent Cashier Department of Veterans Affairs
(Name and address of Department of Veterans Affairs station)

to arrive no later than the due date specified above. B. Complete only if repayment will be through a payroll deduction plan. I authorize a payroll deduction of $ be received on debt is liquidated. 2. I understand that, at the option of the Department of Veterans Affairs, any future benefit payments due to me may be withheld in lieu of this repayment agreement until the indebtedness is liquidated. per pay period, beginning with the salary check to
. This deduction shall remain in effect until the

ADDRESS OF INDIVIDUAL COMPLETING THIS FORM (No. and Street or Rural Route, City, State, ZIP Code)

SIGNATURE

DATE

VA FORM OCT 1992(R)

1100

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