APPLICATION FOR VOLUNTARY SEPARATION INCENTIVE PAY
UNDER VSIP PHASE II
PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 9902(i), DoDD 1400.25, DoD 1400.25-M, Subchapter 1702, "Voluntary Separation Programs".
PRINCIPAL PURPOSE(S): This form serves as a DoD employee application for Voluntary Separation Incentive Pay (VSIP) under
VSIP Phase II. This application specifies how the employee would separate and explains the procedures for approving VSIP
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide required information may result in denial of the application for VSIP.
(Last, First, Middle Initial)
4. DUTY TELEPHONE NUMBER
(Include Area Code)
5. JOB TITLE
8. I am applying for the Voluntary Separation Incentive Pay (VSIP) Phase II Program under the following option
VOLUNTARY EARLY RETIREMENT
9. I understand that the Department of Defense has identified surplus employees potentially available for placement into my
position. This application authorizes the supporting human resources office to formally offer my position to a surplus employee.
If all available surplus employees decline the offer to be placed into my current position, my application shall be considered
When my supporting human resources office is advised that a surplus employee has accepted the offer of my position, my VSIP
Phase II application shall be approved. Then, I shall be committed to voluntary separation and shall be entitled to receive a cash
incentive equal to the lesser of: (1) $25,000, or (2) the amount that I would receive under the formula for computing severance pay. I
understand that once approved, I may not withdraw my application.
I also understand that if the number of VSIP applicants in my skill exceeds the number of surplus employees accepting job offers,
incentive applications shall be approved in order of each applicant's Leave Service Computation Date.
I understand that by accepting separation pay, I may not be reemployed anywhere within the Federal Government, including
employment in nonappropriated fund instrumentalities or with an agency of the United States through a personal services contract
for 5 years after my separation unless I repay the full amount of my separation pay (before taxes and deductions). I also understand
that a DoD employee who receives a buyout may not be employed by the Department of Defense in any capacity for a 12-month
period and is prohibited from registering in the DoD Priority Placement Program.
a. EMPLOYEE SIGNATURE
b. DATE (YYYYMMDD)
10. HUMAN RESOURCES OFFICE USE ONLY
a. LEAVE SCD (YYYYMMDD)
b. DATE APPLICATION APPROVED
c. DATE APPLICANT NOTIFIED OF
DD FORM 2904, OCT 2005
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