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Request for Voluntary Separation Incentive Payments (VSIP)

Agency:

Covered Component(s): 

1. Identify the time period during which VSIPs may be paid (end date)................................... 

2. Identify the maximum number of VSIPs to be paid.......................................................... 

3. Identify the maximum amount to be offered (up to $25,000).............................................. 

4. Describe how the organization will operate without the eliminated/restructured positions and functions. Briefly explain 

in 250 words or less. 

5. Provide a current and proposed organizational chart showing the expected changes to the 

 organization’s structure after completing the VSIP plan........................................................... 

6. If the agency is requesting, or will request, VERA, briefly describe how that authority will be used in conjunction 

with VSIP.

7. If also offering VSIPs under another statutory authority, briefly describe how VSIPs are being used under that authority.

Attached
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8. In Columns 1 to 3, identify the specific positions that will be eliminated/restructured by organizational unit, geographical location, occupational category, grade level, and any 

other factors related to the position such as skills and knowledge gaps you are seeking to address. In Column 5, identify the positions or categories of employees to whom the VSIP 

will be offered in order to achieve the reductions/reshaping specified in columns 1 to 3. [NOTE: Column 5 may include additional categories of employees beyond those whose 

positions are directly targeted for elimination/restructuring (i.e., positions that are not the main focus for reduction/restructuring/elimination, but which are included in the VSIP 

offering only to the extent that they may provide a placement for an employee whose position will be reduced/restructured/eliminated.)] (Attach additional pages as needed)

Positions to be Eliminated/Restructured Positions to be Included in the VSIP Offering

(1)

Organizational 

Unit(s)

(2)

Geographic 

Location(s)

(3)

Occupational Category 

(i.e., title, series, grade, 

and any other positionrelated factors such as 

skills or functions) 

(4)

Indicate whether 

position(s) will 

be eliminated or 

restructured

(5)

Scope/Category of employees who will be offered VSIP

Human Resources 

Department

Washington, DC 

Dallas, TX

Human Resources Assistant, 

GS-203-4 (limited to positions 

performing transactional 

processing work)

Eliminated

Offer will include all positions identified in columns1-3. In addition, the offer will include 

the following positions: GS-203-4 positions in the Services Division, limited to positions 

that perform transactional processing work, and further limited to those who are 

currently eligible for early or regular optional retirement. 
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Agency: 

Agency Contact Information & Signature of Requesting Official

Name: Email: Phone: 

Name of 

Requesting Official: 

 Title of

Requesting Official: 

Signature of Requesting Official

(or attach signed cover memo): ____________________________________________ Date:

________________________________________________________________________________________

OMB Concurrence (OMB Use Only) 

 Concur Do Not Concur

OMB 

Official’s Name: 

 OMB

 Official’s Title: 

OMB Official’s Signature: ______________________________________________ Date:

________________________________________________________________________________________

OPM Decision (OPM Use Only)

 Approved Disapproved

VSIP 

Authorization #: 

 to

 Approval Period: to

 

Approving 

Official’s Name: 

 Approving

 Official’s Title: 

Approving Official’s Signature: ___________________________________________ Date: 

_________________________________________________________________________________________________

Please submit to: 

 

Mailing Address: Deputy Associate Director 

Talent Acquisition and Workforce Shaping

U.S. Office of Personnel Management 

1900 E Street, NW 

Room 6500 

Washington, DC 20415 

Email: employ@opm.gov 

FAX: 202-606-4430