Employee Application For Reimbursement Of Expenses Incurred Upon Sale Or Purchase (Or Both) Of Residence Upon Change Of Official Station
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2EMPLOYEE APPLICATION FOR REIMBURSEMENT OF EXPENSES INCURRED UPON SALE OR
PURCHASE (OR BOTH) OF RESIDENCE UPON CHANGE OF OFFICIAL STATION
(See Privacy Act Notice On Reverse)
A. EMPLOYEE
old official station as provided in Chapter 2, Part 6, of the Federal Travel
Regulation (FTR). The approving official, or his/her designee, will handle
1. Obtain a copy of all supporting documents needed to file your claim.
and execute the approval and return the package to you (see Section D).
Include sales agreements between buyer and seller, settlement or loan
closing statements, invoices and statements that support other items
claimed for reimbursement, etc. Do not send your original supporting
2. For Purchases. Approval of this claim must be executed by the head of
documents as they cannot be returned to you. Send photo copies only.
the office, or his/her designee, at the new official station (unless agency
2. Prepare the front and back of this application in triplicate. Sign and date
review and approval functions are performed elsewhere) (see Section D).
the appropriate employee certification(s).
3. Prepare Form AD-616R, Travel Voucher (Relocation).
3. Final Administrative Approval. Payment of the claim must be executed
4. Submit the original and first copy of Form AD-424, all supporting
by an appropriate approving official (see Section E). Such official shall
documents, and the AD-616R, to the head of your office at new official
independently determine, in accordance with the provisions of the FTR,
station or to the appropriate official designated by your Department or
the propriety of all reimbursements claimed. In this connection, all
agency. Retain the remaining copy of the AD-424 and supporting
vouchers for reimbursement of real estate incident to the same transfer
documents for your records.
shall be examined. Submit the approved AD-616R with attached original
B. HEAD OF OFFICE
AD-424, and supporting documents, to the USDA, National Finance
Center, P.O. Box 60,000, New Orleans, LA 70160. File the copy of the
1. For Sales. Submit the original and first copy of Form AD-424, all supporting
documents, and the AD-616R, to the head of the office at the
claimant’s
application with the office copy of the voucher.
SECTION A - EMPLOYEE
1. SOCIAL SECURITY NUMBER
2. NAME (Last, first, midddle initial)
3. RELOCATION SERVICE
4. HAS EARLIER CLAIM FOR REAL
PREVIOUSLY AUTHORIZED
ESTATE EXPENSES BEEN
FOR THIS TRANSFER
SUBMITTED FOR THIS TRANSFER?
YES
NO
YES
NO
5. MAILING ADDRESS (Street or P.O. Box, City, State, and Zip Code)
SECTION B - TRANSFER DATA
6. OLD OFFICIAL STATION
7. NEW OFFICIAL STATION
8. DATE OF NOTIFICATION OF IMPENDING TRANSFER
9. TRAVEL AUTHORIZATION NUMBER/DATE
10. DATE REPORTED FOR DUTY AT NEW OFFICIAL STATION
11. DATE SERVICE AGREEMENT SIGNED
SECTION C - RESIDENCE PROPERTY DATA
12. SALE (Old Official Station)
13. PURCHASE (New Official Station)
Complete
Address
of Residence
Number of Dweling
Units on Property
Sale and/or
Purchase Price
Date of Closing
or Settlement
Amount of Expense
Being Claimed
I hereby certify that the amount claimed in connection with the above sale repre-
I hereby certify that the amount claimed in connection with the above purchase
sents only amounts actually paid by me and that title to the property was in my
represents only amounts actually paid by me and that title to the property is in
EMPLOYEE
name and/or a member of my immediate family and was my residence when first
my name and/or a member of my immediate family and is my new residence.
CERTIFICATION
definitely informed of my transfer.
OF RESIDENCE
PROPERTY DATA
14. EMPLOYEE’S SIGNATURE
15. DATE
16. EMPLOYEE’S SIGNATURE
17. DATE
SECTION D - APPROVALS
SALE EXPENSES. The expenses of the sale applied for above are hereby
PURCHASE EXPENSES. The expenses of the purchase applied for
approved as being (1) reasonable in amount and (2) customarily paid by a
above are hereby approved as being (1) reasonable in amount and (2) cus-
seller in the locality where the property is located.
tomarily paid by a buyer in the locality where the property is located.
18. As Claimed
19. As Reduced, Per Attached Memo
23. As Claimed
24. As Reduced, Per Attached Memo
20. SIGNATURE
25. SIGNATURE
21. TITLE
26. TITLE
22. DATE
27. DATE
SECTION E - FINAL ADMINISTRATIVE APPROVAL FOR PAYMENT
29. AMOUNT
Payment of this claim is approved in the amount indicated. If the amount approved is less than the amount
claimed, see the attached memo.
30. SIGNATURE
31. TITLE
32. DATE
FORM AD-424 (REV. 4/88)
Clear Form
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