Sf-1190, 2009, Foreign Allowances Application, Grant And Report Page 2
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2Voucher Number
FOREIGN ALLOWANCES APPLICATION, GRANT AND REPORT
19. Employee Name (Last, First, MI)
20. Social Security No.
21a. Payments [Check box(es). For calculations see DSSR chapter exhibits.]
FOR OFFICIAL USE ONLY
TQSA - Temporary Quarters Subsistence Allowance - (DSSR 120)
Advanced
Beg. Date
End Date
Biweekly
Beg. Date
End Date
Lump Sum (upon completion)
Beg. Date
End Date
LQA - Living Quarters Allowance (DSSR 130)
[
]
Repair Allowance (DSSR 137)
[
]
EQA - Extraordinary Quarters Allowance (DSSR 138)
[
]
PA - Post Allowance - (DSSR 220)
Transfer Allowance: Foreign (DSSR 240)
[
]
or Home Service (DSSR 250)
[
]
Portion(s): Subsistence
[
]
Miscellaneous
[
]
Wardrobe
[
]
Lease Penalty
[
]
SMA - Separate Maintenance Allowance - (DSSR 260)
Voluntary
[
]
Involuntary
[
]
TSMA - Transitional Separate Maintenance Allowance (DSSR 260)
262.3a
[
]
262.3b
[
]
262.3c
[
]
262.3d
[
]
262.3e
[
]
[
]
or Travel (DSSR 280)
[
]
Education Allowance (DSSR 270)
PD - Post (Hardship) Differential (DSSR 500)
SND - Service Need Differential (Difficult to Staff Incentive Differential) (DSSR 1000)
DP - Danger Pay (DSSR 650)
[
]
or 652g
[
]
0.00
Total Amount Claimed
21b. Advances
LQA (DSSR 130)
Beg. Date
End Date
Number of Months
U.S. Dollar Payment
Foreign Currency Payment
Transfer Allowance: Foreign (DSSR 240)
[
]
or Home Service (DSSR 250)
[
]
Portion(s): Subsistence
[
]
Miscellaneous
[
]
Wardrobe
[
]
Lease Penalty
[
]
Advance of Pay (DSSR 850) This advance will be repaid in
pay periods.
Travel Authorization or
Permanent Change of Station (PCS) Number
Name of Issuing Authority
22a. If Electronic Funds Transfer (EFT) Mark one:
[
]
Checking
[
]
Savings
Financial Institution Name
Financial Institution Mailing Address
Routing Number
Account Number (including any suffix)
22b. If Paid by Check - Mailing Address, City, State, ZIP 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 and/or differential
authorized herein. I also understand that false statements made to the United States on this form may subject me to criminal 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 31 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
Spouse's or Domestic
Partner's Signature:
Date
(If Applying for SMA on Behalf of Spouse or Domestic Partner)
25. Approving/Reviewing Official Signature When Required
Date
26. Certifying Official: The Above Request is Certified as Correct and Proper for Payment
Date
Authorized Certifying Official's Signature
Page 2 of 2
SF-1190
07-2009
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