Dssr 130 Form – Fill Out and Use This PDF

U.S. Department of State

LQA - LIVING QUARTERS ALLOWANCE ANNUAL/INTERIM EXPENDITURES

WORK SHEET (DSSR 130)

Allowable expenses under the Living Quarters Allowance are reported here to process a claim on the SF-1190. This work sheet is reproducible locally.

1. Employee Name (Last, First, MI)

2. Agency

5.Current Post/Country of Assignment/Locality Code

6.If Spouse or Domestic Partner is Employed by the U.S. Government:

Spouse's or Domestic Partner's Name

Quarters Allowance Received

7. Family Domiciled at Post

8. Family Domiciled Away From Post

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04-2010

9. Description of Quarters Occupied by the Employee

			Date of Quarters Occupied (mm-dd-yyyy)					Quarters Size: Total rooms should include dining room, living room, kitchen,
								bedrooms, den, and bathrooms.
	Type of Quarters				House		Apartment
			Furnished		Unfurnished			Total Rooms
								Total Useable Square Footage
			Privately Leased		Government Owned or Leased
			Personally Owned					or Square Meters
10. If employee shares quarters, give name of person(s) with whom sharing and the employing firm or agency.

11. If employee rents quarters from another U.S. government employee, give name of that employee and employing agency.

12.If employee lets or sublets portion of his owned or leased quarters:

(a)Name of sublessee and employing agency or firm

(b)Amount received from sublessee

(c) Has amount received from sublessee been deducted from expenses claimed under Block 16?

Yes

No

(d)Date let or sublet (mm-dd-yyyy)

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13. Employee Name (Last, First, MI)			14. Check One:
					Estimated or
LQA Expenses for the Period (mm-dd-yyyy)	From	To			Actual

15. FOR OFFICIAL USE ONLY

Foreign currency rate used to compute expenses listed under item 16

For personally owned quarters (POQ), date of original purchase (mm-dd-yyyy)

Exchange rate at time of purchase

Number of years already claimed for rent portion of LQA

Items (a) through (j) are rent and rent-related expenses

(a)Rent, if leased; or 10% of original purchase price, if owned (Claim limit: 10 years)

(b)Garage rental (Not to exceed 25% of maximum LQA rate)

(c)Furniture rental (Not to exceed 25% of maximum LQA rate)

(d)Insurance on rented property and/or furnishings required by local law to be paid by lessee

(e)Taxes levied by the local government and required by law or custom to be paid by lessee

(f)Land rent, if required by local law or custom (Applies only to POQ)

(g)Agent's fee if mandatory by law or custom and is condition of obtaining lease

(h)Apartment/Condominium fees (Excluding single family dwelling and POQ)

(i)Interest on a loan from American Institution To finance "Key Money" paid to landlord

(j)Appreciation fee paid directly to landlord. Must appear on lease or rental agreement

Items (k) through (o) are utilities and utility related expenses

(k)Heat - Gas, Fuel

(I) Electricity

(m)Other Heat, Fuel (specify)

(n)Water

(o)Garbage and Trash Disposal

Total Expenses Claimed For This Period

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17. Remarks

18.For Official Use Only (DSSR 135 and 136)

Quarters Allowance Group		WF ("With Family")		WOF ("Without Family")
Maximum Annual LQA Rate (DSSR 920, Plus 10%, 20%, or 30% For Additional Family Members) =
Daily LQA Rate = Annual LQA Rate Divided By Number Of Days In Calendar Year. Biweekly Rate = Daily Rate Times 14. Any Other Period = Daily Rate Times
Number Of Days Claimed.
Begin Date Claimed (mm-dd-yyyy)				End Date Claimed (mm-dd-yyyy)
Number Of Days Claimed				LQA This Period

19.Employee Statement: I certify that the amounts claimed above were incurred for the period claimed or are estimated to the best of my knowledge for future costs.

Employee's Signature

Date (mm-dd-yyyy)

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