SF1190
Foreign Allowances Application, Grant and Report
Standard Form 1190 (SF 1190) is the Foreign Allowances Application, Grant and Report. Its footer cites the Department of State Standardized Regulations (DSSR) (Government Civilians, Foreign Areas), Section 073.4, and GSA's page lists DSSR Section 073.4 as its authority or regulation. GSA hosts a copy in its forms library.
The Privacy Act statement says the information is used to determine employee eligibility for and appropriate amounts of allowances, that all forms are subject to fiscal audit by the employee's parent agency and GAO, and that the Office of Allowances, U.S. Department of State, will review forms to set LQA rates.
Page 1 asks for the employee's position, post and family members at and away from post. Page 2 lists the allowances and differentials claimed with their DSSR sections, any advances, payment details and accounting classification, then the signatures of the employee, an approving or reviewing official when required and a certifying official. The footer prints the edition as 07-2009. You can fill it out free in your browser on this page and download the result without an account.
Name, Social Security number, agency, bureau or office, pay plan, series, grade, annual salary, position title, current post, country of assignment or locality, date of arrival, previous post, mailing and e-mail address, and for a local hire the date and reason for presence.
A spouse or domestic partner employed by the U.S. Government, family members domiciled at post and away from post with relationship, date of birth except spouse or domestic partner, percent support and dates, and remarks.
Boxes for TQSA, LQA, Repair Allowance, EQA, Post Allowance, Transfer Allowance, SMA, TSMA, Education Allowance or Travel, Post (Hardship) Differential, Service Need Differential and Danger Pay, each with its DSSR section, and a total amount claimed.
LQA advances with dates and number of months, U.S. dollar or foreign currency payment, Transfer Allowance portions, Advance of Pay (DSSR 850) with the number of pay periods to repay it, and the travel authorization or PCS number.
Electronic Funds Transfer to a checking or savings account, with the financial institution, routing number and account number, or a mailing address for a check, and the accounting classification.
The employee statement and signature, a spouse or domestic partner signature for SMA, the approving or reviewing official when required, and the certifying official.
Two pages with items 1 to 26. Boxes for a voucher number and an authorization or grant number are marked for official use only.
Fill in items 1 to 14a, and repeat the employee name and Social Security number in items 19 and 20 on page 2.
Complete items 15 to 17. For family away from post, item 17 asks for residence address, telephone, cell phone and e-mail, and says please provide all.
Item 21a says to check box(es) and, for calculations, to see DSSR chapter exhibits. Enter beginning and end dates where the form asks for them.
Complete item 21b for any advances, then item 22a for Electronic Funds Transfer or item 22b for a check, and item 23 for the accounting classification.
The employee signs and dates item 24. Items 25 and 26 are for the approving or reviewing official, when required, and the certifying official.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The PDF prints no filing address. The employee statement refers to the authorizing office, and items 25 and 26 are signed by an approving or reviewing official and a certifying official.
In item 24 the employee states they understand they are obligated to notify the authorizing office immediately of any change in conditions which may affect the amount of allowances and/or differential authorized.
The statement says that if employment is terminated prior to liquidation of any of these advances, any outstanding amount is due and payable immediately.
The statement says false statements may lead to criminal penalties 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.
Solicitation 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 form says lack of requested information may result in erroneous or unauthorized allowances.
DSSR960EDA
140 fields, 2 pages
GSA5041
9 fields, 1 page
GSA5042
32 fields, 4 pages
GSA5043
6 fields, 1 page
The form names the employee and the officials who sign it. It is an employee and agency form, not one for the public.
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The footer cites the Department of State Standardized Regulations (DSSR) (Government Civilians, Foreign Areas), Section 073.4, with the edition 07-2009. GSA hosts a copy in its forms library, and GSA's page lists DSSR Section 073.4 as its authority.
The employee signs item 24. A spouse or domestic partner signs there too if applying for SMA on their behalf. An approving or reviewing official signs item 25 when required, and a certifying official signs item 26.
Item 21a lists TQSA, LQA, Repair Allowance, EQA, Post Allowance, Transfer Allowance, SMA, TSMA, Education Allowance or Travel, Post (Hardship) Differential, Service Need Differential and Danger Pay, each with its DSSR section.
No. Item 21a says that for calculations, see DSSR chapter exhibits. The form itself prints no rates.
The Privacy Act statement says the Office of Allowances, U.S. Department of State, will review forms to set LQA rates, and that all forms are subject to fiscal audit by the employee's parent agency and GAO.
Item 22a covers Electronic Funds Transfer to a checking or savings account, with the routing and account numbers. Item 22b takes a mailing address if paid by check.
In item 24 the employee states they understand they are obligated to notify the authorizing office immediately of any change in conditions which may affect the amount of allowances and/or differential authorized.