Student Loan Repayment Program Service Agreement Form (Page 2 of 2) in pdf

14. Other condition(s) agreed to by employee and the [AGENCY COMPONENT]:

______________________________________________________________________________________

_____________________________________________________________________________________.

I AGREE TO THE TERMS OF THIS SERVICE AGREEMENT:

Signature ________________________________________ Date ____________

Name (Print/Type) ________________________________

General

This information is provided pursuant to the Privacy Act of 1974 (P.L. 93-597).

Authority for Collection of Information

5 U.S.C 5379

Purpose and Uses

The main purpose for collecting the information requested on this form is to establish the terms under

which an individual receives a student loan repayment benefit under the Student Loan Repayment Program.

The information collected will be used as a basis for payroll actions. Accordingly, disclosure of

identifiable information, including your Social Security Number (SSN), may be made to the Internal

Revenue Service for tax withholding purposes, the Department of Treasury for payroll action, and to the

Department of Labor for worker compensation claims. This information may also be disclosed to the

Department of Justice for other lawful purposes including law enforcement and in the event of litigation.

In addition, these records, or information therefrom, may also be used within [AGENCY] for study

purposes, such as projection of staffing needs, and/or creation of non-identifiable statistical data for reports

to other Federal agencies and Congress.

Information Regarding Disclosure of Your Social Security Account Number

Disclosure of the SSN is mandatory since it is the identifier used by the Internal Revenue Service and for

the withholding of taxes from your salary. The use of the SSN is necessary because of the large number of

present and former employees and applicants who have identical names and birth dates, and whose

identities can be distinguished only by the SSN. It is used primarily to identify an employee’s personnel,

leave, and pay records and to relate on to the other. In this regard, it is also used by the [AGENCY] to

locate records in order to respond to lawful requests for information from former employers, educational

institutions, and financial or other organizations. The information gathered through the use of the number

will be used only as necessary in personnel administration processes carried out in accordance with

established regulations and published notices of systems of records. The SSN also will be used for the

selection of persons to be included in statistical studies of personnel management matters.

Effect of Non-disclosure

Your submission of this agreement is voluntary; however, if the agreement is submitted, omission of

significant information requested would preclude continued processing of the agreement for you to receive

an allowance because payroll would be unable to process the necessary actions.

Student Loan Repayment Program Service Agreement Form Page 2