GSA Form 2255 Service Agreement and Duplicate Reimbursement Disclosure Statement Moving Expense Allowances (Within the United States and Return From Foreign Post)

GSA Form 2255 or the "Service Agreement And Duplicate Reimbursement Disclosure Statement Moving Expense Allowances (within The United States And Return From Foreign Post)" is a form issued by the U.S. General Services Administration.

The form was last revised in June 1, 2012 and is available for digital filing. Download an up-to-date GSA Form 2255 in PDF-format down below or look it up on the U.S. General Services Administration Forms website.

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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.
1. GAINING SERVICE OR STAFF OFFICE
2. TITLE AND GRADE OF POSITION TO BE OCCUPIED
3. EFFECTIVE DATE OF TRANSFER OR APPOINTMENT
4. RESIDENCE ADDRESS AT TIME OF TRANSFER OR APPOINTMENT
5. NAMES OF DEPENDENTS AUTHORIZED TO RELOCATE
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.
7. DATE
6. SIGNATURE OF EMPLOYEE
GENERAL SERVICES ADMINISTRATION
GSA 2255 (REV. 6/2012)
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.
1. GAINING SERVICE OR STAFF OFFICE
2. TITLE AND GRADE OF POSITION TO BE OCCUPIED
3. EFFECTIVE DATE OF TRANSFER OR APPOINTMENT
4. RESIDENCE ADDRESS AT TIME OF TRANSFER OR APPOINTMENT
5. NAMES OF DEPENDENTS AUTHORIZED TO RELOCATE
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.
7. DATE
6. SIGNATURE OF EMPLOYEE
GENERAL SERVICES ADMINISTRATION
GSA 2255 (REV. 6/2012)

Download GSA Form 2255 Service Agreement and Duplicate Reimbursement Disclosure Statement Moving Expense Allowances (Within the United States and Return From Foreign Post)

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