Foreign Allowances Application, Grant and Report Interagency Report Control Number 1170-DOS-AN Voucher Number ________________ 1. Employee Name (Last, First, Middle Initial) _______________________________________ 2. Social Security Number_________________________ 3. Agency______________________ 4. Authorization/Grant Number ____________________ 5. Pay Plan/Series/Grade/Annual Salary ___________________ 6. Position Title ___________________ 7. Current Post/Country/of Assignment/Locality Code _________________________________ 8. Date of Arrival____________________ 9. Previous Post of Assignment _____________________________ 10. Mailing Address ___________________________________ 11. If Local Hire: Date of Arrival at Post/Reason for Presence __________________________ 12. If Spouse is Employed by the US Government: Name/Social Security Number/Allowances received______________________________ 13. Family Domiciled at Post Name of Relative___________________ Relationship ________________________ DOB Except Spouse (MM/DD/YY) ________________ % Support ___________________ Date of Arrival at Post ___________________ Residence Address _______________________________________________ 14. Family Domiciled Away From Post Name of Relative___________________ Relationship ________________________ DOB Except Spouse (MM/DD/YY) ________________ % Support ___________________ Date of Departure from Post ___________________ Residence Address _______________________________________________ 15. 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 employeeÕs 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. Standard Form 1190 (Rev. 1/98) Page 1 of 2 Department of State Standardized regulations (DSSR) (Government Civilians, Foreign Areas), Section 073.4 7540-00-782-3896 Foreign Allowances Application, Grant and Report Voucher Number __________________ 16. Employee Name (Last, First, Middle Initial) ____________________________________ 17. Social Security Number _________________________ 18a. Payments/Entitlements (Check) For calculations see DSSR chapter exhibits. For Official Use Only TQSA-Temporary Quarters Subsistence Allowance (DSSR 120) $ Advance Beg. Date End Date Biweekly Beg. Date End Date Lump Sum (upon completion) Beg. Date End Date LQA-Living Quarters Allowance (DSSR 130) U.S. dollar Payment ____________________ Foreign Currency Payment _________________ PA-Post Allowance (DSSR 220) Transfer Allowance: Foreign (DSSR 260) _____________ or Home Service (DSSR 250) ______________ Portion(s): Subsistence _________________ Miscellaneous __________________ Wardrobe ___________________ Lease Penalty _________________ SMA-Separate Maintenance Allowance (DSSR 280) Education Allowance (DSSR 270) _________________ or Travel (DSSR 260) _______________ PD-Post Differential (DSSR 500) DP-Danger pay (DSSR 650) 652f _________ or 652g __________ Total Amount Claimed _______________ 18b. Advances LQA Beg. Date _____________ End Date _____________ # of Months ________________ U.S. Dollar Payment __________________ Foreign Currency Payment __________________ Transfer Allowance: Foreign ____________ or Home Service _____________ 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 Activity ______________________ Method of Payment 19a. If Electronic Funds Transfer (EFT) Mark one: Checking _______ Savings _______ Financial Institution Name _______________________ Financial Institution Mailing Address _______________________ Routing Number ___________________ Account Number (including any suffix) _______________________ 19b. If by Check ______________________________ Check Mailing Street Address Check Mailing City, State, Zip Code___________________ 20. Accounting Classification(s): _____________________________________________ 21. 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. EmployeeÕs Signature: ___________________________ Date: ___________________ 22. Approving/Reviewing Official Signature When Required: ___________________________ Date: __________________________ 23. Certifying Official: The above Request is Certified ass Correct and Proper for Payment Authorized Certifying OfficialÕs Signature: _________________________ Date: _______________________ Standard Form 1190 page 2 of 2