USDA FOREST SERVICE
FS-6500-272 (10/2011)
FIXED RATE TEMPORARY QUARTERS CERTIFICATION
EMPLOYEE’S CERTIFICATION STATEMENT
EFFECTIVE OCTOBER 1, 2004
EXTENSIONS ARE NOT ALLOWED UNDER THE LUMP SUM METHOD.
(Maximum allowable is 30 days)
Section A – IDENTIFICATION
(This information is required for the processing of the Lump Sum Reimbursement voucher)
1. Name (First, Middle Initial, Last): Please Print
2. Travel Authorization Number:
3. Current Email Address:
Section B – TEMPORARY QUARTERS INFORMATION
4.
INDIVIDUALS WHO WILL OCCUPY TEMPORARY QUARTERS
(List individuals separately including self)
5.
NUMBER OF DAYS CLAIMED
Section D - CERTIFICATIONS
6. I certify that the individuals listed above have occupied temporary quarters.
7. Employee Signature
8. Date:
Section E – REMARKS
9.
Please complete this form and FAX to 1-866-689-4968
USDA FOREST SERVICE
FS-6500-272 (10/2011)
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. Enter current email address
4. List names of authorized individuals who will occupy temporary quarters.
5. Enter number of days claimed for each authorized individual.
6. Read and agree to certification.
7. Certify that you understand agreement in number 6. Traveler’s signature.
8. Enter date signed
9. Enter remarks, if applicable
Useful information
If your agency offers and you select the fixed amount TQSE reimbursement method, you are paid a fixed amount for up
to 30 days. No extensions are allowed under the fixed amount method.
When claiming fixed amount temporary quarters reimbursement:
 Receipts are not required for expenses.

Employee must request Fixed TQ on the FS-6500-140, “Individual’s Request for Authorization.” Once a
reimbursement method has been authorized it cannot be changed.

Employee must complete this ASC-145b, which provides a signed statement to the relocation coordinator of
the number of days in temporary quarters being claimed.