Service Agreement

SERVICE AGREEMENT AND DUPLICATE REIMBURSEMENT DISCLOSURE STATEMENT

MOVING EXPENSE ALLOWANCES

(WITHIN THE UNITED STATES AND RETURN FROM FOREIGN POST)

THIS DOCUMENT ESTABLISHES ELIGIBILITY FOR PAYMENT OF TRAVEL, TRANSPORTATION, AND OTHER MOVING EXPENSES AUTHORIZED BY 5 U.S.C. 5723, 5724, AND 5724a.

In compliance with the Privacy Act of 1974, the following information is provided: Basic authority for requiring the requested information is contained in 5 USC 5701-5733, 20 USC 905, and Executive Order 9397, as amended. Disclosure of the data by you is voluntary. The principal purpose for collecting the data is to determine your eligibility for and amount to reimburse you for expenses incurred in connection with permanent change of duty station travel. Information may be transferred to appropriate Federal, State, or local agencies when relevant to civil, criminal, or regulatory investigators or prosecutions. There is no personal liability to you if you do not furnish the requested information; however, we cannot reimburse you for your expense.

I, , hereby agree to remain in the service of the Government for 12 months following the date I report for duty at my new official station as shown on GSA Form 87, OFFICIAL TDY TRAVEL AUTHORIZATION, and GSA Form 87A, OFFICIAL CHANGE OF DUTY STATION AUTHORIZATION, unless separated for reasons which are beyond my control and are acceptable to the department concerned.

In case of violation of such agreement, any monies expended by the United States on account of travel, transportation, and related moving expenses for myself and immediate family authorized by sections 5723, 5724, and 5724a of Title 5 of the United States Code in connection with my transfer or appointment shall be considered as a debt due to the United States.

I agree that I, and/or my immediate family members, have not accepted, and will not accept, duplicate reimbursement for relocation expenses from public or private sources. Furthermore, to the best of my knowledge, no third party has accepted duplicate reimbursement for my relocation expenses.

I certify that if I have selected the lump sum reimbursement method for temporary quarters expenses, I will occupy temporary quarters and incur actual expenses as a condition to receiving this allowance. I also agree to furnish proof of occupancy if requested by GSA.

I further agree to submit certified tax information and a properly executed SF 1012, TRAVEL VOUCHER, for my Relocation Income Tax (RIT) Allowance within 90 days after receipt of official notice of eligibility from the Region 6, Financial and Payroll Services Division. I understand that payroll deductions will be taken each pay period, in accordance with the Debt Collection Improvement Act of 1996 (DCIA), to recover any Withholding Tax Allowance (WTA) owed the Government caused by my failure to submit the required information.

GENERAL SERVICES ADMINISTRATION     GSA 2255 (REV. 6/2012)