Identifying row
VA file number with any letter prefix, payee number if known, person entitled and receivable code.
VA1100
Agreement to Pay Indebtedness
- Agency
- VA
- Revision
- October 1992
- Fillable fields
- 17
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form VA1100: Agreement to Pay Indebtedness
VA Form VA1100 is the U.S. Department of Veterans Affairs Agreement to Pay Indebtedness. On it, the debtor acknowledges a debt to VA, made up of principal, interest and other costs accrued as of the date, as a result of participation in a benefits program administered by VA.
The agreement offers two ways to repay: minimum monthly payments mailed to the Agent Cashier at a named VA station, or a payroll deduction each pay period until the debt is liquidated. The form leaves the debt amount and payment amounts blank for the debtor to fill in. It also says that, at VA's option, future benefit payments may be withheld in lieu of the agreement until the debt is liquidated.
The PDF is one page with no separate instructions. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form VA1100
Item 1: acknowledgment of debt
The name of the debtor, the type of debt and the amount, which consists of principal, interest and other costs accrued as of this date.
Option A: monthly payments
A minimum monthly payment, the day of each month it is due, the start date, and the VA station to mail it to, to arrive no later than the due date.
Option B: payroll deduction
A deduction per pay period, starting with a named salary check, that remains in effect until the debt is liquidated.
Item 2, address and signature
A statement that future benefit payments may be withheld at VA's option, then the address of the individual completing the form, signature and date.
How to complete VA Form VA1100
- 1
Fill in the top row
Enter the VA file number with any letter prefix, and the payee number, person entitled and receivable code where known.
- 2
Complete Item 1
Write the name of the debtor, the type of debt and the amount owed.
- 3
Choose option A or B
Complete Option A for monthly payments to the VA Agent Cashier, or Option B for a payroll deduction. Each option says to complete it only for that repayment method.
- 4
Add your address, sign and date
Enter the address of the individual completing the form, then sign and date it.
Why fill Form VA1100 on indox
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Where it goes
Submission
The form prints no mailing address for the signed agreement. Option A names the VA station whose Agent Cashier receives monthly payments.
No online version
VA's page offers the form as a downloadable PDF only.
Edition
The footer reads VA FORM OCT 1992(R) 1100, and VA's page gives a form revision date of October 1992.
Related forms
Who uses VA Form VA1100?
The form is written in the debtor's own words, from "I, (Name of Debtor)".
Official sources and the blank
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Questions about Form VA1100
What is VA Form VA1100 used for?
It is a written agreement in which a debtor acknowledges a debt to VA from participation in a VA benefits program and sets out how it will be repaid.
What repayment methods does the form offer?
Option A, minimum monthly payments mailed to the Agent Cashier at a VA station, and Option B, a payroll deduction per pay period until the debt is liquidated.
Does the form say how much to pay?
No. The debt amount, the monthly payment and the payroll deduction are blanks for the debtor to fill in.
Can VA hold back future benefit payments?
Item 2 says that, at the option of VA, any future benefit payments due may be withheld in lieu of the repayment agreement until the indebtedness is liquidated.
When are monthly payments due?
On the day of each month the debtor writes in Option A. The form says the payment is mailed to arrive no later than that due date.