USDA – Forest Service
FS-6500-0140 (04/2012)
INDIVIDUAL’S REQUEST FOR TRANSFER OF STATION AUTHORIZATION
DO NOT BEGIN TRAVEL OR INCUR EXPENSES UNTIL YOUR TRAVEL AUTHORIZATION IS APPROVED.
2. Social Security Number:
3. Primary E-Mail Address:
XXX-XXAlternate E-Mail Address:
4. Request Type:
5. Current Federal Employee:
Yes
No
Issue Original Authorization
Amend Authorization
If Yes, Current Agency:
Retirement System:
CSRS or
FERS
Amendment Request Dated
1. Name Of Employee:
6. New Position is :
7. Current Government (USDA FS) Credit Card:
Yes
No
New Series/Grade/Step:
8. Request Authority To Incur Allowable Expenses In Connection With My Move:
a. FROM:
b. TO:
Old Official Station (Street, City, State, Zip Code)
New Official Station (Street, City, State, Zip Code)
c. FROM:
d. TO:
Residence Address (Street, City, State, Zip Code)
Residence Address (Street, City, State, Zip Code) (if known)
e. Home Phone: (Area Code)
f. Office Phone: (Area Code)
g. Alternate Phone: (Area Code)
h. Report Date at New Official Station:
9a. Immediate Family Moving With Employee:
b. Relationship:
c. Birth Date:
d. Marital Status (M/S)
10. EMPLOYEE’S SERVICE AGREEMENT, LUMP SUM TEMPORARY QUARTERS CERTIFICATION, WITHHOLDING TAX ALLOWANCE NOTIFICATION, and
DUPLICATE REIMBURSEMENT DISCLOSURE (FTR 302-2, 302-3, 302-6, and 302-17)
I agree to remain in the service of the Federal Government for 12 months following the effective (report) date of my transfer, unless separated for reasons beyond my
control and acceptable to the Government. In case I violate this agreement, any monies expended by the United States on account of my relocation, which includes all
payments for travel, transportation, shipment and storage of household goods, real estate transactions, and other moving expenses shall be recoverable from me as a
debt due the United States.
I certify that if I choose the Lump Sum Temporary Quarters (TQSE) Reimbursement Method, I may be paid prior to occupancy of my/our temporary quarters. I certify
that I and/or my immediate family will occupy temporary quarters and will incur TQSE. If no TQSE is incurred, I acknowledge that I will be required to return all monies
advanced for the lump sum TQSE payment to the agency. I understand that the agency has the authority at any time to request proof that I/we actually occupied
temporary quarters, even if not for the full length of time on which the lump sum calculation was based. In absence of sufficient proof of TQSE occupancy, the agency
may demand repayment of the TQSE lump sum payment.
I further agree that if I receive Withholding Tax Allowance (WTA) payments for claims filed for relocation expenses, I will: (1) file for a Relocation Income Tax
Allowance (RIT) and (2) submit all required documentation of income with the claim for RIT no later than August 31 of the year following the WTA payments. If I am
overpaid WTA or do not file my RIT claim, I agree to repay the Government the amount of WTA billed by the United States in connection with my transfer.
I certify that I and/or my immediate family have not accepted, and will not accept, duplicate reimbursement of any relocation expenses from another Government
agency or private source. To the best of my knowledge, no third party has accepted duplicate reimbursement for my relocation expenses.
11. Signature of Transferring Employee:
12. Current Position Title:
13. Date:
14. Administrative Approval:
I approve the request subject to the applicable rates and limitations specified by applicable travel regulations.
I approve the request subject to the applicable rates and limitations specified by applicable travel regulations with the following attached administrative
statements or modifications of this agreement as deemed necessary
15. ASC B&F Approving Officer’s Signature:
16. Title:
17. Date:
CAUTION The Comptroller General and the Civilian Board of Contract Appeals has ruled that employees who are transferring may not receive reimbursements until they agree to remain
with the Government 12 months after the effective date of the transfer and the travel authorization has been approved by competent authority.
SOCIAL SECURITY NUMBER Public Law 93-579 (Privacy Act of 1974) includes specific requirements pertaining to requests for individuals to disclose their social security numbers.
Disclosure by you of your social security number may be deemed mandatory for the purpose of processing your transfer of station expense reimbursement voucher. Solicitation of the
social security number is authorized under 5 U.S.C. 301 and 7 CFR 2.75.
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USDA – Forest Service
FS-6500-0140 (04/2012)
18. Employee Name: (First, Middle, Last):
19. Househunting Trip: (Once authorized selection cannot be changed)
Have you been assigned to Government or other prearranged housing at your new official station?
One round trip to seek residence quarters at new official station for:
Self
Spouse
Method of Reimbursement
Lump Sum OR
Per Diem
Mode of travel will be by:
Airplane
Personal Auto
Other (Explain)
Planned dates of travel:
From:
To:
20. En-route Travel:
a. One-way trip between old and new official stations for permanent assignment:
Self
Mode of travel will be by:
Airplane
Personal Auto
Other (Explain)
Planned dates of travel are:
From:
To:
b. Request the use of a second privately owned vehicle:
Yes
No
Yes
No
Immediate Family
21. Transportation and Storage of Household Goods:
a. Transportation of
Rooms of household goods and personal effects.
b. Total estimated weight:
Pounds
c. Estimated pickup date:
d. Method of transportation:
I elect to have my goods moved by the Government contractor.
List Heavy or Bulky Items to be shipped in Block 30.
e. Will you be shipping Professional Books, Papers, and Equipment (PBP&E)?
Yes
No
I elect to perform a self-move of household goods.
22. Allowance for Transportation of Mobile Home Used as a Primary Residence (In lieu of transportation and storage of household goods):
I certify the mobile home transported at government expense will be my and/or my family’s primary residence at destination.
23. Transportation and Storage of Private Vehicle:
Year, Make and Model of Vehicle being shipped:
24. Miscellaneous Expenses Allowance as:
Single employee
Employee with immediate family
25. Temporary Quarters Subsistence Expenses: (Once authorized selection cannot be changed)
a. For:
Self
b.
Lump Sum for
Immediate Family
days (30 Days Maximum) OR
Actual Expense Method for 30 days
26. Foreign Transfers Only:
Foreign Transfer Allowance
27. Foreign Transfers and Temporary Change of Station Only:
Property Management Services
Estimated Monthly Cost: $
Temporary Quarters Subsistence Allowance
28. Real Estate Transaction(s):
a. Estimated market value of residence being sold: $
b. Names on title of residence to be sold:
c.
Sale of residence using Direct Reimbursement Procedure
I elect to utilize the 3rd Party Relocation Services Program to sell my residence
d.
Unexpired lease (Lease termination) Amount of Lease Termination: $
e.
Purchase a new residence at new official duty station
29. I choose to utilize the following destination services offered by GSA contract relocation company:
Buyer’s Assistance
Mortgage Counseling
Rental Assistance
30. Remarks:
_
_ Block 19. Lump Sum House Hunting Trip to seek residence quarters at the new official station: I have elected to be reimbursed for House Hunting through the Lump
Sum payment method.
_
_ Block 25b. Lump Sum Temporary Quarters Subsistence Expense (TQSE): I have elected to be reimbursed for TQSE through the Lump Sum payment method which
may be paid prior to occupancy of my/our temporary quarters. I am requesting _
_days of TQSE reimbursement through the Lump Sum method.
_
_ Block 28c. I elect to utilize the Relocation Services Program to sell my residence at my old duty location. I understand I must list my residence with a licensed real
estate broker prior to entering the Relocation Services Program and failure to do so will result in denial of entry into the Relocation Services Program.
31. Employee’s Initials
32. Date:
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USDA – Forest Service
Instructions
FS-6500-0140 (04/2012)
1.
2.
3.
4.
Enter your complete legal name (First, Middle Initial, Last). Nicknames are not acceptable.
Enter only the last four digits of your social security number.
Enter primary and alternate electronic (email) address.
Check “Issue Original Authorization” if initial request; check “Amend Authorization” if requesting an amendment to your AD-202 Travel Authorization. If amending authorization,
enter date of request for amendment.
5.
Check “Yes” if you are a current federal employee; If Yes: enter your current agency and check your current retirement plan. If “No”, skip to next box.
6.
Enter your new position title and new series/grade/step. This information can be found on your confirmation letter.
7.
Check “Yes” if you have a current Government (USDA FS) Travel Card. Check “No” if you do not have a Government (USDA FS) Travel Card.
8a.
Enter the complete physical address of the old duty station, including Street, City, State, and Zip Code.
8b.
Enter the complete physical address of the new official duty station, including Street, City, State, and Zip Code.
8c.
Enter the complete physical address of the residence from which you currently commute to and from work on a daily basis, including Street, City, State, and Zip Code.
8d.
Enter the complete physical address of new residence, including Street, City, State, and Zip Code, if known.
8e.
Enter current home phone number.
8f.
Enter current office phone number.
8g.
Enter alternate phone number or new duty station phone number.
8h.
Enter the estimated date you are scheduled to physically report to work at the new duty station. This can be found on your confirmation letter.
9a.
Enter the name(s) of each immediate family member (dependent) who will be transferring. Proof of dependency for other than spouse and minor children may be required. If more
space is required, annotate additional information in Block 30.
9b.
Enter relationship of named family member.
9c.
Enter birth dates of family members other than spouse. If requesting authorization for dependents 21 or over, complete Block 30 and justify the dependents’ inclusion on the
authorization.
9d.
Enter the marital status of each immediate family member listed. “M” = Married; “S” = Single
10.
Read the employee’s service agreement. Original, signed FS-6500-0140 must be sent to the ASC B&F, Transfer of Station Section before travel vouchers can be processed.
11.
Sign using legal signature.
12.
Enter current title.
13.
Enter the date FS-6500-0140 is signed.
14-17. Completed by ASC B&F Approving Officer
18.
Enter your complete legal name (First, Middle, Last). Nicknames are not acceptable.
NOTE: If you are considered a new appointee, you will only need to fill in Blocks 20 and 21.
19.
Check if requesting a house-hunting trip. Duty Station to Duty Station mileage must exceed 75 miles to qualify, other restrictions may apply. Check applicable box stating if you
have been assigned Gov’t or prearranged housing. Check applicable boxes for travelers, method of reimbursement, and mode of travel and enter the travel dates. Note: Only
expenses incurred by authorized travelers are reimbursed. If the LUMP SUM reimbursement method is selected go to Block 30 on Page 2, initial next to Block 19.
20.
Check box to request reimbursement of Enroute Travel (One-Way Move) to the new duty station
20a.
Check applicable box(es) for travelers and mode of travel. Enter estimated travel dates. Note: Only expenses incurred by authorized travelers are reimbursed.
20b.
Check applicable box to request a second privately owned vehicle. “Y” = Yes; “N” = No (No more than two vehicles are authorized).
21.
Check this box if you are requesting shipment/storage of your household goods.
21a.
Enter number of rooms to be packed and shipped (excluding bathrooms and hallways).
21b.
Enter estimated weight of household goods. If unsure of weight of household goods, use 1,500 pounds for each room of furniture plus estimated weight of heavier items like a
piano, freezer, etc. Weight cannot exceed 18,000 pounds; excess weight will be billed directly by NFC.
21c.
Enter estimated date of packing and pickup of household goods.
21d.
Check applicable box(es) for the method of transporting your household goods. Note: If you elect to do a “self-move”, weight certificates are required for loads both empty and full.
Receipts and proof of payment are required for reimbursement of actual expenses. List your Heavy and Bulky items in Block 30.
21e.
Check applicable box. If you have Professional Books and Equipment (PBP&E) that will take you above the 18,000 lb allowance for household goods, it will need to be shipped
separately as an administrative cost. You will need to inventory these items and have them approved by your new supervisor in advance of shipment. Approval form will need to
be completed by employee and new supervisor in advance of shipment.
22.
Check if transportation of a mobile home is requested in lieu of transportation and storage of household goods. The maximum cost to transport a mobile home cannot exceed the
cost of transporting 18,000 pounds of household goods and 90 days of temporary storage. The mobile home transported to the new official station must be used as primary
residence of employee and/or the immediate family. Enter your initials to certify that your mobile home will be your primary residence at the new duty station.
23.
Check if you will be shipping a POV. Shipment of a POV must be advantageous to the government. You are limited to one (1) POV if you are moving to, from, or between
OCONUS duty stations. You may ship one (1) POV if your duty stations are within CONUS and your old and new duty stations are at least 600 miles apart; a cost comparison will
be required.
24.
Check applicable box.
25.
Check this box if you are requesting temporary quarters subsistence expenses.
25a.
Check applicable box(es) for travelers who will incur temporary quarters subsistence expenses.
25b.
Check applicable box(es) to request TQSE. If LUMP SUM Reimbursement Method is selected, enter the number of days you are requesting. Note: a maximum of 30 days may be
authorized, no extensions are allowed. In Block 30, enter your initials next to Block 25b and enter the number of days requested for Lump Sum TQSE after you have read and
agree to the terms and conditions.
26.
Foreign Transfer use only. Check applicable box(es) to request authorization for Foreign Transfer Allowance (pre-departure allowance) and/or Temporary Quarters Subsistance
Allowance(TQSA) (Foreign Duty Station). TQSA can only be used if you do not have government provided housing or permanent housing available at the time of arrival.
27.
Foreign Transfer and Temporary Change of Station use only; enter estimated monthly cost for property management services.
28.
Check this box if you have any requests for residence transactions at the old or new duty station.
28a.
Enter estimated selling price for residence listed in Block 8c, if applicable. This estimate is used to establish an obligation for real estate expenses. If checked, complete 28c.
28b.
List names of individuals who are on the title of residence listed in Block 8c. Also include the full name(s) of any individual who is named on the title of the residence listed in Block
8c, even though not a family member and provide explanation in Block 30.
28c.
Direct Reimbursement Procedure: Check this box if you will be selling your residence on your own and will not be requesting entry into the Relocation Services Program;
employee will request reimbursement of allowable closing costs associated with sale. NOTE: Home Marketing Incentive does not apply.
3rd Party Relocation Services Program (RSP): Check this box if you will request entry into the RSP. Note: Not all properties qualify for RSP. In Block 30, initial statement for
28c. Home must be marketed by employee, if home is to be entered into the Relocation Services Program.
28d.
Check box, if you have a lease termination fee for the residence you commute to and from your old duty station. Enter the amount of your lease termination fees.
28e.
Check box if you plan to purchase a residence at the new duty station; employee will request reimbursement of allowable closing costs associated with purchase.
29.
Check this box if you are requesting destination services for buyer’s assistance, rental assistance, or mortgage counseling through the agency relocation services contract. Check
the applicable box(es).
30.
Enter required remarks and/or justifications. See also Blocks 9(a-d), 19, 25b, 28 (b-c).
31.
Initial here to verify the requested items are correct and complete.
32.
Enter date you initialed the second page of this document.
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