USDA FOREST SERVICE FS-6500-274 (02/14/12)

LUMP SUM TEMPORARY QUARTERS CERTIFICATION
EMPLOYEE’S CERTIFICATION STATEMENT
EFFECTIVE AUGUST 1, 2011
EXTENSIONS ARE NOT ALLOWED UNDER THE LUMP SUM METHOD.
(Maximum allowable is 30 days)
Section A – IDENTIFICATION
(This information is required for the processing of the Lump Sum Reimbursement voucher)
1. Name (First, Middle Initial, Last) Please Print / 2. Travel Authorization Number:
3. Current Email Address:
Section B – TEMPORARY QUARTERS INFORMATION
4.
INDIVIDUALS WHO WILL OCCUPY TEMPORARY QUARTERS
(List individuals separately including self)
The employee and dependents will be reimbursed based on the per diem in effect at the time of employee’s report date and will be determined by how many days the employee occupies Temporary Quarters (TQ) as requested below.
5.
NUMBER OF DAYS CLAIMED BY EMPLOYEE
AT OLD DUTY STATION / 6.
NUMBER OF DAYS CLAIMED BY EMPLOYEE
AT NEW DUTY STATION
Section D - CERTIFICATIONS
7. I certify that the individuals listed above will occupy and incur temporary quarters. If no temporary quarters expenses are incurred, I acknowledge that I will be required to return all monies advanced for the Lump Sum TQ payment to the agency, including the withholding tax allowance received.
8. Employee Signature / 9. Date:
Section E – REMARKS
10.

Please complete this form and FAX to 1-866-689-4968

Instructions
Fax completed form to 1-866-689-4968
1.  Enter your legal name (first name, middle initial, last name). Nicknames are not accepted.
2.  Enter travel authorization number.
3.  Enter current email address
4.  List names of authorized individuals who will occupy temporary quarters.
5.  Enter number of days claimed by employee at old duty location.
6.  Enter number of days claimed by employee at new duty location.
7.  Read and agree to certification.
8.  Certify that you understand agreement in number 7. Traveler’s signature.
9.  Enter date signed
10.  Enter remarks, if applicable
Useful information
When claiming your advanced lump sum temporary quarters reimbursement:
·  Employee must request Lump Sum TQSE on the FS-6500-0140, “Individual’s Request for Authorization.” Once a reimbursement method has been authorized it cannot be changed.
·  The per diem rate is determined by your report date. The employee and dependants will be reimbursed the same number of days based on the same per diem rate(s) that coincide with the request made in section 5 and 6 of this form.
·  You must have completed the certification that you will occupy temporary quarters on your service agreement. If
you do not occupy temporary quarters you must repay the lump sum temporary quarters payment in accordance with FTR 302-6.305. Proof of occupancy may be requested by the agency for temporary quarters.
·  You must complete this ASC-145c, which provides a signed statement to the relocation coordinator of the number
of days in temporary quarters being claimed.