Sf-1190, 2006, Foreign Allowances Application, Grant And Report Page 2
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1
2FO REIG N A L L O WA N CE S A P P L I CA T I ON, GRAN T AN D REPO RT
Voucher Number
1
mployee Name (Last. First Ml)
20. Social Securitv No
a 4 ^
ts{Check box(es). (For calculations see DSSR chapter exhibits
F O R O F F I C I A L U S E O N L Y
TQSA - Temoorary Quarters Subsistence Allowance - (DSSR 120)
Advanced
Beg. Date (mm-dd-yyyy)
End Date (mm-dd-yyyy)
Biweekly
Beg. Date (mm-dd-yyw)
End Date (mm-dd-yyyy)
Lump Sum (upon completion) Beg. Date (mm-dd-yyyy)
End Date (mm-dd-yyyy)
LQA - Living Quarters Allowance (DSSR 730)
t
1
Repair Allowance (DSSR 732) [
EQA - Extraordinary Quarters Allowance (DSSR 738) t
l
PA - Post Allowance - (DSSR 220)
Transfer Allowance: Foreign (DSSR 240) | |
I or Home Service (DSSR 250) t
1
P o r t i o n ( s ) : S u b s i s t e n c e [
]
M i s c e l l a n e o u s [ ]
W a r d r o b e [
]
L e a s e P e n a l t y [
]
SMA - Separate Maintenance Allowance - (DSSR 260)
V o l u n t a r y [
] I n v o l u n t a r y [
]
TS[,4A - Transitional Separate Maintenance Allowance (DSSR 260)
Unaccompanied Post [
]
Completion of School Semester
t
Education Allowance (DSSR 270)
t
I or Travel (DSSR 280,) t
1
PD - Post (Hardship) Differential (DSSR 500.)
SND - Service Need Differential (Difficultto Staff lncentive Differential) (DSSR 1000)
DP - Danger Pay (DSSR 650) 652f t
I or 6529
Total Amount Glaimed
2 1 b . A d v a n c e s
LOA rDSSR 730)
Beg. Date (mm-dd-yyyy)
End Date (mm-dd-yyyy)
Number ot Months
U.S. Dollar Payment
Foreign Currency Payment
Transfer Allowance: Foreign (DSSR 240)
[
] or Home service
(DSSR 25o)
t
1
Portion(s): Subsistence [
] Miscellaneous [
] wardrobe [
]
LeasePenalty I
Advance of Pay (DSSR 850) This advance will be repaid in
Travel Authorization or
pay periods
Permanent Change of Station (PCS) Number
Name of lssuing Authority
22a.lf Electronic Funds Transfer /EFI) Mark one:
[
] C h e c k i n g
[
] S a v i n g s
Financial lnstitution N ame
Financial Institution Mailing Address
R o u t i n g N u m b e r
Account Number (including any suffix)
22b. lf Patd by Check - Mailing Address, crty, state, LIP code
23. Accounting Classification(s)
24. Employee Statement and Signature: The information given on this application is true and correct to the best of my knowledge and belief. I also
understand that I am obligated to notify the authorizing office immediately of any change in conditions which may affect the amount of allowances
a n d / o r d i f f e r e n t i a l
a u t h o r i z e d h e r e i n . l a l s o u n d e r s t a n d t h a t f a l s e s t a t e m e n t s m a d e t o t h e U n i t e d S t a t e s o n t h i s f o r m m a y s u b j e c t m e t o c r i m i n a l
penalties (including fines and imprisonment) under 18 U.S.C. 287 and 1001 and/or civil penalties under 31 U.S.C. 3729 or administrative penalties
under 3'1 U.S.C. 3802. I understand if my employment is terminated prior to liquidation of any of these advances, any outstanding amount is due and
payable immediately.
Employee's Signature:
Date (mm-dd-yyyy)
Spouse's Signature:
Date (mn-dd-yyyy)
(lf Applying for SMA on Behalf of Spouse)
Daie (mm-dd-yyyy)
ztj. certriyrng ottrcral: I ne Above Kequest rs uenrlreo as uorrect ano Proper lor Payment
Authorized Certifying Official's Signature
Date (mm-dd-yyyy)
s F - 1 1 9 0
Page 2 ot 2
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