Foreign Allowances Application, For Official Use Only Grant

FOREIGN ALLOWANCES APPLICATION, GRANT AND REPORT (SF-1190)

1. Employee Name (Last, First, MI)

2. Social Security Number

3. Agency

4. Bureau/Office

5. Pay Plan

6. Series

7. Grade

8. Annual Salary 9. Position Title

FOR OFFICIAL USE ONLY Voucher Number
Authorization/ Grant Number

10. Current Post/Country of Assignment/Locality

11. Date of Arrival

12. Previous Post of Assignment

13. Mailing Address

13a. E-mail Address

14. If Local Hire: Date

14a. Reason for Presence

15. If Spouse or Domestic Partner is Employed by the U.S. Government Spouse or Domestic Partner Name (Last, First, MI)

Yes

No

Social Security Number

Allowances Received

16. Family Domiciled at Post Name of Family Member

Relationship

DOB Except Spouse or Domestic Partner

% Support

Date of Arrival at Post

Allowances Received

17. Family Domiciled Away from Post Name of Family Member

Relationship

DOB Except Spouse or Domestic Partner

% Support

Date of Departure from Post

Residence Address/Telephone Cell Phone/E-mail (please provide all)

18. Remarks

Privacy Act Statement: Solicitation of this information is authorized under 5 U.S.C. 5922, E.O. 9397 and E.O. 10903, Section 1(b-2) and DSSR Section 073.4. The information is used to determine employee eligibility for and appropriate amounts of allowances. All forms are subject to fiscal audit by the employee's parent agency and GAO. The Office of Allowances, U.S. Department of State, will review forms to set LQA rates. Lack of requested information may result in erroneous or unauthorized allowances.

SF-1190 07-2009

Department of State Standardized Regulations (DSSR) (Government Civilians, Foreign Areas), Section 073.4

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FOREIGN ALLOWANCES APPLICATION, GRANT AND REPORT
19. Employee Name (Last, First, MI)

21a. Payments [Check box(es). For calculations see DSSR chapter exhibits.]

TQSA - Temporary Quarters Subsistence Allowance - (DSSR 120)

Advanced

Beg. Date

End Date

Biweekly

Beg. Date

End Date

Lump Sum (upon completion) Beg. Date

End Date

LQA - Living Quarters Allowance (DSSR 130) [ ]

Repair Allowance (DSSR 137) [ ]

EQA - Extraordinary Quarters Allowance (DSSR 138) [ ]

PA - Post Allowance - (DSSR 220)

Transfer Allowance: Foreign (DSSR 240) [ ]

or Home Service (DSSR 250) [ ]

Portion(s): Subsistence [ ]

Miscellaneous [ ]

Wardrobe [ ] Lease Penalty [ ]

SMA - Separate Maintenance Allowance - (DSSR 260)

Voluntary [ ] Involuntary [ ]

TSMA - Transitional Separate Maintenance Allowance (DSSR 260)

262.3a [ ]

262.3b [ ]

262.3c [ ]

262.3d [ ]

262.3e [ ]

Education Allowance (DSSR 270) [ ] or Travel (DSSR 280) [ ]

PD - Post (Hardship) Differential (DSSR 500)

SND - Service Need Differential (Difficult to Staff Incentive Differential) (DSSR 1000)

DP - Danger Pay (DSSR 650) [ ]

or 652g [ ]

Total Amount Claimed

21b. Advances

LQA (DSSR 130)

Beg. Date

End Date

Number of Months

U.S. Dollar Payment

Foreign Currency Payment

Transfer Allowance: Foreign (DSSR 240) [ ]

or Home Service (DSSR 250) [ ]

Portion(s): Subsistence [ ] Miscellaneous [ ] Wardrobe [ ] Lease Penalty [ ]

Advance of Pay (DSSR 850) This advance will be repaid in

pay periods.

Travel Authorization or

Permanent Change of Station (PCS) Number

Name of Issuing Authority

22a. If Electronic Funds Transfer (EFT) Mark one: Financial Institution Name

[ ] Checking

[ ] Savings

Financial Institution Mailing Address

Voucher Number 20. Social Security No. FOR OFFICIAL USE ONLY
0.00

Routing Number 22b. If Paid by Check - Mailing Address, City, State, ZIP Code

Account Number (including any suffix)

23. Accounting Classification(s)

24. Employee Statement and Signature: The information given on this application is true and correct to the best of my knowledge and belief. I also understand that I am obligated to notify the authorizing office immediately of any change in conditions which may affect the amount of allowances and/or differential authorized herein. I also understand that false statements made to the United States on this form may subject me to criminal penalties (including fines and imprisonment) under 18 U.S.C. 287 and 1001 and/or civil penalties under 31 U.S.C. 3729 or administrative penalties under 31 U.S.C. 3802. I understand if my employment is terminated prior to liquidation of any of these advances, any outstanding amount is due and payable immediately.

Employee's Signature:

SIGN HERE

Date

Spouse's or Domestic Partner's Signature:

SIGN HERE

(If Applying for SMA on Behalf of Spouse or Domestic Partner)

Date

25. Approving/Reviewing Official Signature When Required

SIGN HERE

26. Certifying Official: The Above Request is Certified as Correct and Proper for Payment

Authorized Certifying Official's Signature

SIGN HERE

SF-1190 07-2009

Date Date

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