USDA Forest Service
R10-FS-6500-0002 (04/2013)
Initial Overseas Employment Agreement
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:
No :
Yes, Current Agency:
Issue Original Authorization
Amend Authorization, Request Dated
Retirement System:
CSRS or
FERS
1. Name Of Employee:
6. New Position is :
New Series/Grade/Step:
7. Current Government (USDA FS) Travel Credit Card:
Yes
No
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 Post of Duty (Street, City, State, ZIP Code)
c. FROM:
d. TO:
Current Place of Residence (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 Post of Duty:
9a. Immediate Family Moving with Employee:
b. Relationship:
c. Birth Date:
d. Marital Status (M/S)
10. EMPLOYEE’S SERVICE AGREEMENT, WITHHOLDING TAX ALLOWANCE NOTIFICATION, and DUPLICATE REIMBURSEMENT DISCLOSURE (Federal
Travel Regulation (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, such as reduction in force. 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, including withholding tax allowance. Any monies deemed recoverable from me as a debt due the United
States may be deducted from my final salary payment, be deducted from my retirement benefits, and/or become a garnishment from my wages.
If I complete my 12 month service agreement, I understand that the Government will fund my return travel to my actual place of residence in the contiguous United
States (CONUS), defined as in 8(c) above as my Current Place of Residence. If I separate from the Forest Service upon completion of my service agreement, the
Forest Service will fund the return travel in accordance with the Federal, Department, and Agency Travel Regulations. If I transfer to or separate from a different
Federal Government Agency upon completion of my service agreement(s), the gaining agency will be responsible for my return travel. (Note: I must provide a copy of
this service agreement to my new agency.) I understand if I do not complete this service agreement or if I have a break in Federal Government service, my return
travel benefits are void and the Government will not be obligated for returning me or my immediate family to my current place of residence.
I understand that eligibility for Overseas Employment Renewal Agreement Travel (OTRAT) is no longer available for new transfers to Alaska. If I believe that I am
eligible for this recruiting and retention incentive based on a previous transfer to Alaska, I will review the eligibility requirements in booklet, R10-RG-058, Overseas
Employment Renewal Agreement Travel Information, and talk with my supervisor if I believe that I am eligible for this recruiting and retention incentive.
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 Decision by Albuquerque Service Center, Budget & Finance (ASC B&F):
I approve the mandatory and the optional entitlements 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. Agency Approval: ASC B&F Approving Officer’s Signature:
16. Title:
Page 1 of 3
(Refer to Region 10 supplements to FSH 6509.33, chapter 302 for more information.)
17. Date:
USDA Forest Service
R10-FS-6500-0002 (04/2013)
18. Employee Name: (First, Middle, Last):
19. Househunting Trip (optional):
a. Have you been assigned to Government or other prearranged housing at your new official station?
b. One round trip to seek residence quarters at new official station for:
Self
Spouse
Mode of travel will be by:
Airplane
Privately Owned Vehicle (POV)
Other (Explain)
Planned dates of travel:
From:
To:
c. Method of Reimbursement:
Lump Sum (complete block 30) OR
Per Diem
Yes
No
20. En-route Travel:
a. One-way trip between old and new official stations for permanent assignment:
Self
Immediate Family
Mode of travel will be by:
Privately Owned Vehicle (POV)
Ferry
Airplane
Other (Explain)
Planned dates of travel are:
From:
To:
b. Request the use of a second privately owned vehicle (optional):
No
Yes (enter reasons for requesting second POV in block 30)
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 & storage of household goods): Complete block 30.
23. Shipment and Storage of Privately Owned Vehicle (optional): Year, make, and model of vehicle being shipped:
24. Miscellaneous Expenses Allowance as:
Single employee
Employee with immediate family
25. Temporary Quarters Subsistence Expenses (optional):
a. For:
Self
Immediate Family
b. Method of Reimbursement:
Lump Sum Method (complete block 30)
OR
27. Temporary Change of Station Only:
Property Management Services (optional)
Actual Expense Method
Estimated Monthly Cost: $
28. Real Estate Transaction(s):
a. Estimated market value of residence being sold: $
b. Names on title of current place of residence:
c.
Sale of residence using Direct Reimbursement Procedure OR
Sale of my residence using the Third Party Relocation Services Program (optional) OR
Assistance renting your current place of residence while serving outside CONUS (optional)
d.
Unexpired lease with lease termination fee:
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 General Services Administration (GSA) contract relocation company:
Buyer’s Assistance
Mortgage Counseling
Rental Assistance
30. Remarks:
_
_ Block 19. Lump Sum Method of Reimbursement for Househunting Trip to seek residence quarters at the new official station. I have elected to be
reimbursed for househunting through the Lump Sum payment method. I understand that once I make this election it cannot be changed.
Block 22. Transportation of Mobile Home as a Primary Residence. I certify the mobile home transported at government expense will be my and/or my
family’s primary residence at my post of duty.
_
_ Block 25b. Lump Sum Method of Reimbursement for 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. I understand that once I make this election it cannot be changed. 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.
_
_ 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 that failure to do so will result in denial of entry into the Relocation Services
Program.
31. Employee’s Initials
32. Date:
Page 2 of 3
(Refer to Region 10 supplements to FSH 6509.33, chapter 302 for more information.)
USDA Forest Service
1.
2.
3.
4.
5.
6.
7.
8a.
8b.
8c.
8d.
8e. - 8f.
8g.
8h.
9a. - 9b.
9c. - 9d.
10.
11.
12.
13.
14. - 17.
Instructions
R10-FS-6500-0002 (04/2013)
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 your primary and alternate electronic (email) addresses.
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.
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.
Enter your new position title and new series/grade/step. This information can be found on your confirmation letter.
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.
Enter the complete physical address of the old duty station, including street, city, state, and ZIP code.
Enter the complete physical address of the new post of duty outside of the contiguous United States (OCONUS), including street, city, state, and ZIP code.
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.
Enter the complete physical address of the new residence, including street, city, state, and ZIP code, if known.
Enter your current home phone number and current office phone number.
Enter your alternate phone number or new duty station phone number.
Enter the date you are scheduled to physically report to work at the new post of duty. This can be found on your confirmation letter.
Enter the name(s) of each immediate family member (dependent) who will be transferring. Proof of dependency for any person other than spouse and minor children may be
required. If more space is required, annotate additional information in block 30. Enter relationship of named family member.
Enter birth dates of family members other than spouse. If requesting authorization for dependents age 21 years or over, complete block 30 and justify the dependents’ inclusion
on the authorization. Enter the marital status of each immediate family member listed. “M” = Married; “S” = Single
Read the employee’s service agreement. Original, signed form must be sent to the ASC B&F, Transfer of Station Section before travel vouchers can be processed.
Sign using legal signature.
Enter title of your current position.
Enter the date that the form is signed.
Completed by the ASC B&F approving officer. Read the Government agreement and sign using legal signature, print the approving officer’s work title, and print the date that the
form is signed.
NOTE: If you are considered a new appointee, you only need to fill in blocks 18, 20, and 21 on page 2 of this form.
18.
19.
20.
20a.
20b.
21.
21a.
21b.
21c.
21d.
21e.
22.
23.
24.
25.
25a.
25b.
26.
27.
28.
28a.
28b.
28c.
28d.
28e.
29.
30.
31.
32.
Enter your complete legal name (first, middle, last). Nicknames are not acceptable.
Check if requesting a househunting 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 Government 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, refer to block 30, read the statement, and initial next to
“Block 19.”
Check box to request reimbursement of en-route travel (one-way move) to the new duty station.
Check applicable box(es) for travelers and mode of travel. Enter estimated travel dates. Note: Only expenses incurred by authorized travelers are reimbursed.
Check applicable box to request a second privately owned vehicle. “Y” = yes; “N” = no. Note: No more than two vehicles are authorized. Record reason for requesting use of
second POV, such as having more dependents in immediate family than can fit in one POV.
Check this box if you are requesting shipment/storage of your household goods.
Enter number of rooms to be packed and shipped (excluding bathrooms and hallways).
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, and so forth. Weight may not exceed 18,000 pounds; excess weight will be billed directly by NFC.
Enter estimated date of packing and pickup of household goods.
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.
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, they 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. The employee and new
supervisor will need to complete an approval form in advance of shipment.
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 the 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.
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 post of duty.
Check applicable box.
Check this box if you are requesting temporary quarters subsistence expenses.
Check applicable box(es) for travelers who will incur temporary quarters subsistence expenses.
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
agreed to the terms and conditions.
Intentionally left blank.
Temporary change of station use only. Enter estimated monthly cost for property management services.
Check this box if you have any requests for residence transactions at the old or new duty station.
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.
List names of individuals who are on the title of the 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.
Direct Reimbursement Procedure: Check this box if you will sell your residence on your own and will not request entry into the Relocation Services Program. Employee will
request reimbursement of allowable closing costs associated with sale. Note: Home Marketing Incentive does not apply.
Third 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 RSP.
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.
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.
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).
Enter required remarks and/or justifications. See also blocks 9a-d, 19, 25b, and 28b-c.
Initial here to verify the requested items are correct and complete.
Enter date you initialed the second page of this document.
Page 3 of 3
(Refer to Region 10 supplements to FSH 6509.33, chapter 302 for more information.)