Dssr 130 Form – Fill Out and Use This PDF

Enter the Employee Name (Last, First, MI.), 2. Agency, Pay Plan/Series/Grade/Annual Salary, 4. Date of(mm-dd-yyyy) and the Current Post/Country of Assignment/Locality Code.

If Spouse or Domestic Partner is Employed by the U.S. Government, enter the Spouse's or Domestic Partner's Name and the Quarters Allowance Received.

Under Family Domiciled at Post, enter the Name of Family Member, Relationship, DOB Except Spouse or Domestic Partner (mm-dd-yyyy), Percentage of Support, Date of Arrival at Post (mm-dd-yyyy) and Residence Address.

Under Family Domiciled Away From Post, enter the Name of Family Member, Relationship, DOB Except Spouse or Domestic Partner (mm-dd-yyyy), Percentage of Support, Date of Departure from Post (mm-dd-yyyy) and Residence Address.

For the Description of Quarters Occupied by the Employee, enter the Date Quarters Occupied (mm-dd-yyyy).

Type of Quarters: House or Apartment; Furnished or Unfurnished; Privately Leased, Government Owned or Leased, or Personally Owned.

Quarters Size: Total rooms should include dining room, living room, kitchen, bedrooms, den, and bathrooms. Enter Total Rooms and Total Useable Square Footage or Square Meters.

If employee shares quarters, give name of person(s) with whom sharing and the employing firm or agency.

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

If employee lets or sublets portion of his owned or leased quarters, enter (a) Name of sublessee and employing agency or firm, (b) Amount received from sublessee, (c) Yes or No to Has amount received from sublessee been deducted from expenses claimed under Block 16? and (d) Date let or sublet (mm-dd-yyyy).

Check One: Estimated or Actual. Enter the LQA Expenses for the Period (mm-dd-yyyy) From and To.

The following expenses were actually incurred or are estimated for the period claimed in Block 14.

Expenses should be supported by lease or rental agreement, receipts or canceled checks. If unobtainable, explain why under Block 17, Remarks.

Enter each expense in (A) Foreign Currency Expenses and (B) U.S. Dollar Expenses.

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. Enter the Total Expenses Claimed For This Period.

Remarks

Sign on Signature and enter the Date (mm-dd-yyyy).

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.