Fillable Standard Form 1190 - Foreign Allowances Application, Grant And Report printable pdf download

Standard Form 1190 - Foreign Allowances Application, Grant And Report

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INTERAGENCY REPORT CONTROL

VOUCHER NUMBER

FOREIGN ALLOWANCES APPLICATION,

NUMBER

GRANT AND REPORT

1170-DOS-AN

1. EMPLOYEE NAME (LAST, FIRST, MIDDLE INITIAL)

2. SOCIAL SECURITY NUMBER

3. AGENCY

4. AUTHORIZATION/GRANT NUMBER

5. PAY PLAN/SERIES/GRADE/ANNUAL SALARY

6. POSITION TITLE

7. CURRENT POST/COUNTRY OF ASSIGNMENT/LOCALITY CODE

8. DATE OF ARRIVAL

9. PREVIOUS POST OF ASSIGNMENT

10. MAILING ADDRESS

11. IF LOCAL HIRE: DATE OF ARRIVAL AT POST/REASON FOR PRESENCE

12. IF SPOUSE IS EMPLOYED BY THE US GOVERNMENT: NAME/SOCIAL SECURITY NUMBER/ALLOWANCES RECEIVED

Active Duty

US Civilian

13. FAMILY DOMICILED AT POST

NAME OF RELATIVE

RELATIONSHIP

DOB EXCEPT

DATE OF ARRIVAL

RESIDENCE ADDRESS

SPOUSE

SUPPORT

AT POST

(MM/DD/YY)

14. FAMILY DOMICILED AWAY FROM POST

NAME OF RELATIVE

RELATIONSHIP

DOB EXCEPT

DATE OF

RESIDENCE ADDRESS

SPOUSE

SUPPORT

DEPARTURE

(MM/DD/YY)

FROM POST

15. REMARKS

Privacy Act Statement: Solicitation of this information is authorized under 5 U.S.C. 5922, E.O. 9397 and E.O. 10903, Section 1(b-2) and DSSR Section 073.4

The information is used to determine employee eligibility for and appropriate amounts of allowances. All forms are subject to fiscal audit by the employee's

parent agency and GAO. The Office of Allowances, U.S. Department of State, will review forms to set LQA rates. Lack of requested information may result

in erroneous or unauthorized allowances.

STANDARD FORM 1190

7540-00-782-3836

(REV. 1/98)

PAGE 1 OF 2

DEPARTMENT OF STATE STANDARDIZED REGULATIONS (DSSR)

(GOVERNMENT CIVILIANS, FOREIGN AREAS), SECTION 073.4