STATION NUMBER

EMPLOYEE'S CLEARANCE FROM INDEBTEDNESS (Virtual)

FULL NAME OF EMPLOYEE: HRSMART EMPL ID: FORWARDING
ADDRESS:

Michael McPherson 00476278 PHONE NUMBER:

EMAIL ADDRESS:
TITLE OF JOB POSITION IF I AM CLEARED FROM INDEBTEDNESS, I WOULD LIKE MY FINAL CHECK TO: INITIALS
OF
Medical Support Assistant CONTINUE AS CURRENTLY DIRECTED EMPLOYEE
NAME OF SERVICE, DIVISION, AND SUPERVISOR
BE MAILED BY THE AGENT CASHIER TO THE FORWARDING ADDRESS
V20 CCC- Elizabeth Ierome PROVIDED ABOVE
THE EMPLOYEE IS (Check one) SEPARATION DATE THE EMPLOYEE IS (Check one)
TRANSFERRING TO (last paid day)
✔ RESIGNING RETIRING (Specify) 08/19/2022 ✔ VETERAN NON-VETERAN
NOTE: Asterisk (*) indicates that there is a designated coordinator within your organization.
VA TRANSFER CLEARANCE OFFICIAL ARTICLE QTY. UNIT COST TOTAL COST
*Equipment Inventory List (EIL) Computers, Lap Tops, Pagers,
IT (transfer ownership) Cell Phones, Blackberry, etc.
Other:

SEPARATION/ RETIREMENT
CLEARANCE OFFICIAL ARTICLE QTY. UNIT COST TOTAL COST
LOSS TO ANOTHER AGENCY
*Equipment Inventory List (EIL) Computers, Lap Tops, Pagers,
IT Cell Phones, Blackberry, etc.
Security and Law Enforcement ID Badge
Name Removal -
*Info. Security Officer VA's Computer System
Human Resources Benefits Briefing and Exit Interview,
Exit Survey/Transfer Survey
Child Care Subsidy I certify that I am not receiving child care subsidy from VA. SIGNATURE OF EMPLOYEE
(Note: The Clearance Official is
the employee for child care I certify that I am receiving child care subsidy from VA and I agree to notify the
subsidy.) Fed. Employee & Assistance Fund of impending separation. Call 1 (877) 541-4556.
*Credit Card Citibank Visa Card

Credit Union/Canteen Status of Account(s)

Employee Health Unit Medical Records

Other:

ALL SEPARATIONS CLEARANCE OFFICIAL ACTION NEEDED SUBMITTED APPROVED BY PROCESSED

Incentive Service Agreement(s) Human Resources Review agreement requirements.

Resignation/Expiration/Removal
MSS Action Supervisor 5/18/2022 ehi
Loss to Another Agency

Agent Cashier Final Clearance

MET WITH EMPLOYEE DATE CLEARANCE EMPLOYEE CLEARED FINAL CHECK PROCESSED FINAL CHECK SENT TO INITIALS OF PAYROLL
FOR RECEIVED BY MAIL FROM INDEBTEDNESS AS REQUESTED AGENT CASHIER TECHNICIAN
PAYROLL YES
USE
NO (If "NO," complete YES NO YES NO YES NO
ONLY next block.)
SHORTAGES NOTED ON VOUCHER NO. DATE OF VOUCHER

NOTE: This form must be completed prior to presenting to the Agent Cashier (your last stop). The Agent Cashier will conduct a mandatory final clearance review to allow
you to receive your final payment.
CERTIFICATION: I certify that I am aware of the criminal penalties for the unlawful removal of Federal records (Title 18, U.S. Code 2071), and that I do not have any
Government Records or property other than that which I am properly authorized to possess.
SIGNATURE OF EMPLOYEE DATE

SIGNATURE OF APPROVING OFFICIAL DATE INITIALS OF DATE INDEBTEDNESS COLLECTED

AGENT
CASHIER $
SCHEDULE NO. DATE

VA FORM
AUG 2019 3248