FS Form 2889 U.S. Department of the Treasury Stored Value Card Contra

For official use only Cardholder Name:				OMB No. 1530-0013
U.S. DEPARTMENT OF THE TREASURY STORED VALUE CARD CONTRACTOR AGREEMENT
DIRECTIONS: This form collects supplemental information pertaining to an applicant for an SVC card who is not an employee of the U.S. Department of Defense. The applicant also must complete FS Form 2887. Submit completed form to Disbursing or Finance Office or other authorized person responsible for coordinating enrollment for Treasury SVC program. For more information about the Treasury SVC programs, please visit eaglecash.gov or navycash.gov.
PRIVACY ACT STATEMENT AUTHORITY: P.L. 104-134, Debt Collection Improvement Act 1996, as amended; 5 U.S.C. 5514; 31 U.S.C. Sections 1322 and 3720A; 37 U.S.C. Section 1007; 31 CFR 210 and 285; and E.O. 9397. PRINCIPAL PURPOSE(S): To enroll individuals in the Treasury SVC program and to facilitate collection of any delinquent amounts that may become due and owing as a result of your use of the Treasury SVC. ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act of 1974, as amended. It may be disclosed outside of the U.S. Department of the Treasury to its Fiscal and Financial Agents and their contractors involved in providing SVC services, or to the Department of Defense (DoD) for the purpose of administering the Treasury SVC programs. In addition, other Federal, State, or local government agencies that have identified a need to know may obtain this information for the purpose(s) as identified by the Bureau of the Fiscal Service (Fiscal Service) Routine Uses as published in the Federal Register. DISCLOSURE: Disclosure is voluntary; however, failure to furnish requested information may significantly delay or prevent your participation in the Treasury SVC program.
BURDEN ESTIMATE STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time required to complete this information collection is estimated to average 10 minutes, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Comments concerning the accuracy of the time estimate and suggestions for reducing this burden should be directed to the U.S. Department of the Treasury, Bureau of the Fiscal Service, 401 14th Street SW, Washington DC 20227.
PLEASE PRINT OR TYPE ALL INFORMATION (Information Must Be Legible)
1. NAME (First, Middle Initial, Last)						2. SOCIAL SECURITY NUMBER
3. HOME ADDRESS (Street, Apartment Number, City, State, ZIP Code)
4. PESONAL CELL PHONE NUMBER	5. PERSONAL EMAIL ADDRESS		6. DRIVER’S LICENSE STATE & # or COUNTRY/PASSPORT #
7. EMPLOYER NAME		8. EMPLOYER EMAIL ADDRESS				9. EMPLOYER PHONE NUMBER
10. EMPLOYER ADDRESS (Street, Suite Number, City, State, ZIP Code)
11. SUPERVISOR’S NAME (First, Middle Initial, Last)		12. SUPERVISOR’S EMAIL ADDRESS				13. SUPERVISOR’S PHONE NUMBER
STATEMENTS OF UNDERSTANDING DEBT COLLECTION/WAIVER OF PRIOR DUE PROCESS: In consideration of receiving a Treasury SVC, I understand that, if any amounts become due and owing as a result of my use of the Treasury SVC, the government will initiate debt collection procedures in accordance with the Federal Claims Collections Standards (31 CFR 900-904) and Chapters 28-32, Volume 5, DoD 7000-14-R, DoD Financial Management Regulation. ADDITIONAL TERMS AND CONDITIONS: By using the Treasury SVC, I agree to accept the terms and conditions for use of the Treasury SVC established by the issuer of the card. Issuance of a Treasury SVC is conditional upon your employer’s confirmation of employment and their agreement to certain obligations. Your employer’s failure to promptly agree to such obligations may result in the suspension and/or termination of your participation in the Treasury SVC card program. I agree to the release of my personal information and information about my Treasury SVC account to the employer listed above for the purposes of verifying my employment with the entity and for the purposes of administering the Treasury SVC program. This form may be imaged and kept on file electronically by the U.S. Department of the Treasury and/or its Financial or Fiscal Agent. The electronic image shall be considered the legal equivalent of the original.
14. REQUESTOR’S SIGNATURE						15. DATE

Department of the Treasury | Bureau of the Fiscal Service FS Form 2889