Form 126 – Fill Out and Use

PURPOSE

The OF-126 form is used to (1) designate residences for travel and shipment of effects; (2) to record relationship status; (3) to list dependents; and (4) to show current home leave address. If residence, dependency, or relationship status information is different from what was previously submitted, please mark the appropriate box for the change made. Your agency will assume all residence and dependency information in your file is correct unless you submit a revised OF-126 form. Please check the appropriate box at the top of the form for this submission. NOTE: This form cannot be used for state tax withholding requests or changes.

RESIDENCE INFORMATION

The residences listed for home leave and separation are residences to which you will be authorized travel and shipment of effects. Please provide house/apartment number, street, city, state/zip code for both.

Legal Residence (item 4): The CITY and STATE you claim as your legal residence.

Home Leave Residence (item 5 (a) current address, (b) new address): The location in the U.S. where you expect to spend your home leave. The address you claim is subject to approval. The justification (Item 6) for the selection or change of home leave residence must be based on a close family tie or other compelling interests and not simply on a desire to visit the location or for personal convenience. Valid justifications for changes of home leave address include death, relocation of a relative whose address was previously claimed, better climate needed for recorded health problem, sale or purchase of residential or business property, or change of legal residence. Requests for changes of home leave address will be reviewed on a case-by-case basis. Changes based on a prospective event cannot be approved. Home leave residence may not be changed after travel orders have been issued without the prior approval of an appropriate authorizing officer in Washington, D.C.

Residence for Service Separation (item 8): The residence in the United States to which you would want to travel and utilize for authorized shipment of effects when you separate from service (14 FAM 546; 585.2 Arranging & Procuring Indirect Travel; Indirect Travel). While such designation is the location where you expect to reside or to be employed, it is also the location where remains are shipped if death occurs while abroad or while in travel status. If remains are shipped to a different location, shipment is made on a cost construct basis (14 FAM 536.2 Death of U.S. Citizen Employee). This information is also used for separation of family members by reason of divorce, children who have reached the age of 21, resignation and retirement.

This form must be resubmitted prior to the retirement separation. Please check the box at the top of the form marked "Separation/Retirement." No location/address change can be made after the effective date of the separation or once travel has commenced.

Relationship Status (item 9): Accurate relationship status information is necessary for your agency to project costs for family travel and to ensure that travel orders are prepared accurately. Item 12 (c) "Place" shows place of marriage or execution of domestic partner affidavit. Spouse or domestic partner (as defined in 3 FAM 1610) will be authorized travel from this place of origin. Please check only the status code that describes your relationship status to a Foreign Service or Civil Service employee. Please note that Item 13 (b) "Change of Dependents" must be completed for each event denoted in Item 12 (a) "Change of Relationship Status."

DEPENDENCY INFORMATION

A dependent may be a spouse or domestic partner, children under age 21, or a relative who is at least 51% dependent on you for support (subject to review and approval of supporting documentation by the approving official as noted in Item 13 (a); an update is required with each new assignment abroad). Attach documentation such as a monthly summary of income and expenses from ALL sources as evidence of support (expenses you pay/relative expenses (excluding charge cards) or some other documentary evidence of support) to substantiate a claim for any relative other than a dependent spouse, domestic partner, or children under age 21. Children of divorced employees, spouses, or domestic partners cannot be listed on travel orders unless (a) a copy of the divorce decree establishing that the employee has physical custody of the children is on file in the appropriate personnel office (in joint custody cases, a notarized statement from the ex-spouse or ex-domestic partner authorizing the children to reside abroad is also required); and (b) children meet the dependency criteria contained in 14 FAM 511.3 Definitions - "Eligible Family Members" (1) - (4). Travel will not be authorized for dependents unless a current OF-126 form has been approved listing the names of the dependents before the travel order has been produced. Amending travel orders to add or to delete dependents causes delays in employee travel. Children who reach the age of 21 will be automatically traveled to the employee’s separation location, unless the Medical Division provides HR/EX/ASU with information indicating that the child is permanently or temporarily dependent on the employee. Otherwise, the employee should submit an OF-126 form to officially remove the child from their record. Post personnel officer's signature only indicates that the form and required documentation appear to be complete. (AID employees also see Supplement 1B to HB32, Chap 1.)

NOTE: Keeping dependent information up to date ensures the coverage of eligible dependents under your agency's medical program. Parents and siblings are not covered (16 FAM 122.2).

Distribution:

State: HR/EX

AID: See Supplement 1B to HB32, Chapter 1

VOA P/F - Foreign Personnel Advisor

Commerce: Office of Foreign Service Human Resources

Agriculture: FAS/Personnel, APHIS/Human Resources Division; or appropriate agency Personnel Office.

Copies: Original to personnel office; Copy retained by post Admin Section

Name of Dependent

Relationship

Citizenship

Date of Birth

(mm-dd-yyyy)

(b) Change of Dependents (Name)

Relationship

Date of Birth

(mm-dd-yyyy)

Citizenship

Gain/Loss

Place

Date of Gain

(mm-dd-yyyy)

Reason

Dependents Approved

Dependents Disapproved

15. Person to Notify in Case of an Emergency

(Name, Address, Telephone Number)

NOTICE: Any willful and material misrepresentation made on this form may result in a fine of not more than $10,000 or imprisonment of not more than five years or both. (18 USC 1001)