Attachment A "Employee Application for Intrastate Relocation Expense Reimbursement" - Georgia (United States)

What Is Attachment A?

This is a legal form that was released by the Georgia Department of Juvenile Justice - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Download a printable version of Attachment A by clicking the link below or browse more documents and templates provided by the Georgia Department of Juvenile Justice.

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Download Attachment A "Employee Application for Intrastate Relocation Expense Reimbursement" - Georgia (United States)

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Attachment A, DJJ 2.7
DEPARTMENT OF JUVENILE JUSTICE
EMPLOYEE APPLICATION FOR INTRASTATE RELOCATION EXPENSE REIMBURSEMENT
EMPLOYEE INFORMATION
DATE_______________________
Employee Name ________________________________________
Title _____________________________________
Division/Section ________________________________________
Supervisor _________________________________
Date employed by Department _____________________________
Dependents Living at Home: Number __________
Name
Relationship
Age
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
RELOCATION INFORMATION
Distance Between Old
Old Address
New Address
& New Locations*
1. Duty Station
________________________________________________________________________________________
2. Residence
________________________________________________________________________________________
3. Distance* from Old Residence to: Old Duty Station _______________ New Duty Station _____________
4. Expected Date of Move____________
5. Date of Transfer __________________
6. Reason to Transfer _______________________________________________________________________________________
7. Is any other family member being reimbursed for this move?
Yes
No
8. Number of personal vehicles ____________________
*Distance between towns as shown on the official Georgia Highway Map published by the Georgia Department of Transportation.
ESTIMATED EXPENDITURES
Type of Expenditure
Estimated Amount
9.
Transportation and subsistence to look for new residence
_______________
(number of days ______ and number of trips ________)
10.
Transportation and subsi s tence during move (no. of days _____)
_______________
11.
Transportation of household goods (check the method to be used)
commercial moving van
self-move
mobile home
_______________
12.
Utility reconnection
_______________
13.
Other (specify) ______________________________________________________
_______________
Total
_______________
Attachment A, DJJ 2.7
DEPARTMENT OF JUVENILE JUSTICE
EMPLOYEE APPLICATION FOR INTRASTATE RELOCATION EXPENSE REIMBURSEMENT
EMPLOYEE INFORMATION
DATE_______________________
Employee Name ________________________________________
Title _____________________________________
Division/Section ________________________________________
Supervisor _________________________________
Date employed by Department _____________________________
Dependents Living at Home: Number __________
Name
Relationship
Age
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
RELOCATION INFORMATION
Distance Between Old
Old Address
New Address
& New Locations*
1. Duty Station
________________________________________________________________________________________
2. Residence
________________________________________________________________________________________
3. Distance* from Old Residence to: Old Duty Station _______________ New Duty Station _____________
4. Expected Date of Move____________
5. Date of Transfer __________________
6. Reason to Transfer _______________________________________________________________________________________
7. Is any other family member being reimbursed for this move?
Yes
No
8. Number of personal vehicles ____________________
*Distance between towns as shown on the official Georgia Highway Map published by the Georgia Department of Transportation.
ESTIMATED EXPENDITURES
Type of Expenditure
Estimated Amount
9.
Transportation and subsistence to look for new residence
_______________
(number of days ______ and number of trips ________)
10.
Transportation and subsi s tence during move (no. of days _____)
_______________
11.
Transportation of household goods (check the method to be used)
commercial moving van
self-move
mobile home
_______________
12.
Utility reconnection
_______________
13.
Other (specify) ______________________________________________________
_______________
Total
_______________
Attachment A, DJJ 2.7
MOVING COMPANY INFORMATION
(This section is to be completed, where applicable, if you anticipate transporting your household goods within a commercial
moving van or within your mobile home.)
15. Check and complete as appropriate:
a.
Commercial Moving Van
Number of Rooms of Furniture to be Moved ____________
Estimated Weight ______________
b.
Standard Mobile Home
Expandable Mobile Home
Double-Wide Mobile Home
c.
Length _______ft.
Unassembled width _______ft.
16. Estimated value of household goods $ _____________
Mobile Home $ _____________
17. Name and Address of Moving Company Contacted: _________________________________________________
___________________________________________________________________________________________
18a. Services Provided by Moving Company (for example: packing, wardrobe, etc.) *Some services may not be reimbursable
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
b. Estimated Cost $ ___________ (Include in the Estimated Expenditure Section, Line 11)
EMPLOYEE CERTIFICATION AND AGREEMENT
The information contained in this application is completed and accurate. I also understand that my receipt of funds for the
reimbursement of allowable expenses resulting from the relocation described in this application will obligate me to work for this
department in the new location for at least twelve (12) months from the date the relocation is completed, unless separated or
transferred for reasons beyond my control and acceptable to the department or to refund, in full, the amount reimbursed.
________________________________________
____________________________
Employee Signature
Date
AUTHORIZATION
The relocation expense reimbursement applied for is recommended as being in accordance with State law and with State and
Department regulations governing relocation expense reimbursement.
___________________________________________
____________________________
Supervisor
Date
Sufficient funds are available within the Department’s budget to cover the relocation expenses estimated in this application.
___________________________________________
____________________________
Fiscal Officer
Date
The relocation described in this application is hereby authorized and certified to be in the best interest of the Department and the
State of Georgia.
___________________________________________
____________________________
Department Head
Date
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