USDA Forest Service
FS-6500-255 (09/01/2011)
EXPENSE RECORD FOR ONE-WAY MOVE/SELF-MOVE OF HOUSEHOLD GOODS
1. Name:
2. Travel Authorization Number:
3. Traveler(s) Include(s):
Self
Spouse
Dependents (List below)
Name/Age
Name/Age
4. Travel Itinerary: (Lodging receipts required)
Departure
Date
From: City/State
Time
Arrival
Time
To: City/State
Lodging
Expense
$
Lodging
Tax
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Daily
Mileage
5. Privately Owned Vehicle (POV) Odometer Readings:
Primary POV:
2nd POV (Must be authorized):
Beginning Odometer Reading:
Beginning Odometer Reading:
Ending Odometer Reading:
Ending Odometer Reading:
6. Transportation Expenses: (Must be authorized and receipts required)
Check One:
Government Transportation System (GVTS)
Government Travel/Personal Credit Card
Name of Carrier
7. Miscellaneous Expense Allowance:
Ticket Total
Employee
TMC Fee
$
$
$
$
Dependents
8. Other Miscellaneous Expenses:
Date
Amount
Description (i.e., parking, taxi, shuttle, toll fees, etc.)
$
$
$
9. Self-Move/Self-Storage of Household Goods: (Complete this section only if you were authorized, receipts and weight certificate(s) required)
Company Name:
Weight Certificate – Empty
(Tare)
lbs.
Contract Total:$
Weight Certification – Full
(Gross)
lbs.
Total Gas: $
Boxes, Packing Material: $
Total Days in Storage:
Storage Total:$
10. Remarks:
11. I would like my reimbursement sent to:
My salary address (current Forest Service employees only)
Special address (i.e. travel EFT ):
12. Daytime Phone Number:
13. Current Email Address:
14. Employee Signature:
15. Date:
USDA Forest Service
FS-6500-255 (09/01/2011)
INSTRUCTIONS
Fax completed form to 1-866-689-4968
1. Enter your legal name (first name, middle initial, last name). Nicknames are not accepted.
2. Enter travel authorization number.
3. Check applicable boxes and enter the applicable names and ages of dependent children. Attach additional sheet(s)
if necessary.
4. Enter travel itinerary. Enter dates in mm/dd/yy format. You must travel an average of 300 miles per day to receive
per diem. Plan your trip so that you are staying within the commuting area of the old or new duty location during
your one-way move. If you are in commuting area, this could be considered temporary quarters.
5. Enter beginning and ending odometer readings for authorized POV(s).
6. Check applicable method of payment for common carrier. Enter data for each traveler’s transportation expense
(plane, train, or bus, if applicable). Primary method of payment should be on Government Transportation System
(GVTS). Personal credit card use is allowed only if person does not have a government credit card and
transportation was not charged to GVTS. Attach additional sheet(s) if necessary.
7. Check applicable box for reimbursement of approved Miscellaneous Expense Allowance.
8. Enter data for other miscellaneous expense(s) as applicable. Enter dates in mm/dd/yy format. Attach additional
sheet(s) if necessary.
9. Provide data for self-move/self-storage of household goods. Only complete this section if you transported and/or
stored your household goods on your own.
10. Enter remarks, if applicable
11. Check method of payment. Enter special address information if applicable
12. Enter daytime contact number, including area code
13. Enter current email address
14. Traveler’s signature
15. Enter date signed
Useful information
You will only be reimbursed for authorized expenses. All requested expenses must be authorized and approved prior to
beginning travel.
You must submit receipts for the following authorized expenses:





Tolls and other allowable miscellaneous items not listed below. (over $75.00)
Parking
Baggage cost
Lodging
Transportation (plane, train, bus, etc.)
Written explanation/justification is required for any unusual circumstances that may affect your reimbursement (i.e. inclement
weather forced use of alternate route or delay in travel).
Attach a separate sheet if necessary.