USDA - FOREST SERVICE
FS-6500-141 (05/12)
REQUISITION AND AUTHORIZATION FOR RELOCATION SERVICES
(Reference FSH 6509.133, FSTR 2-12)
1.
TO: (Contractor's Name & Address)
Capital Relocation Services
44112 Mercure Circle
Sterling, VA 20166
2. FROM: (Region & Billing Address)
USDA, Forest Service
Albuquerque Service Center –TOS
4000 Masthead St. NE
Mailstop 202
Albuquerque, NM 87109
3.
4.
7.
Contractor's Account No:
GSA Contract No.
GS-33F-0002P
Employee Name
#
5. Travel Authorization No.
6.
Accounting:
10.
8. Social Security Number
N/A
Name(s) included on title of old residence (note relationship, if any)
9.
Forest Service E-mail
11.
Address of Residence to be Sold
13.
Zone No.
14.
Old Home Phone No.
16.
Address of New Residence (if known)
17. New Official Station Address
18.
New Home Phone No.
19. New Work Phone No.
20.
Expected Arrival Date at New Official Station
21. Name of a Contact at New Offical Station
22.
Service Requested by Employee
23. Authorizing Information:
12. Old Official Station Address
(1) Northwest; (2) Pacific Southwest; (3) Mountain; (4) Midwest; (5) Southwest;
(6) Mid South
15. Old Work Phone No.
Date
a. Home Sale Service
b. Home Finding Assistance:
Buyer's Assistance
Rental Assistance
c. Mortgage Counseling
24.
26.
d. Phoned in Order
e. Emailed in Order
f. Faxed in Order
Regional Relocation Services Coordinator (RRSC) Name.
Supv. Financial Analyst
RRSC Authorizing Signature
25.
27.
Phone No.
505-944-83
Date
The Privacy Act of 1974 (PL 93-579) Statement: 5 U.S.C. 301, 7 CFR 2.75, and FSH 6509.33, authorizes collection of this information. Collection
of social security number is authorized by E.O. 9397, and furnishing such is voluntary, but failure to do so may delay processing this request.