Living Quarters Eligibility Questionnaire; GSA Form 5039

Forms and Documents

Document Name	Status
Form GSA 5039 Living Quarters Eligibility Questionnaire; GSA Form 5039 Form and Instruction	New
GSA Form 5039 Supporting Statement (1).docx Supporting Statement A	2023-09-20

IC Document Collections

IC ID	Document Title	Status
262266	Living Quarters Eligibility Questionnaire; GSA Form 5039 Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202309-3090-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: GSA	Agency Tracking No:
Title: Living Quarters Eligibility Questionnaire; GSA Form 5039
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/20/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	25	0
Time Burden (Hours)	25	0
Cost Burden (Dollars)	0	0

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Abstract: This information collection activity concerns an agency-specific form, GSA Form 5039, Living Quarters Allowance Eligibility Questionnaire. This form would be completed by job candidates who have been selected for appointment, reassignment, promotion, or transfer to civil service positions in foreign areas (i.e., outside the United States and its territories and possessions). The living quarters allowance is an authority which allows an agency to reimburse the cost of rent for private housing in an overseas area. The purpose of the form is to collect information which is necessary to determine eligibility for this quarters allowance, under the terms of sections 031.12 and 130 of the State Department’s Standardized Regulations (DSSR). The individuals completing this form will be either members of the public (i.e. not yet appointed to Federal service) or existing Federal employees already employed by GSA or currently appointed by a different agency within the Executive Branch of the U.S. Government.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 16447	05/16/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 64912	09/20/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Living Quarters Eligibility Questionnaire; GSA Form 5039	GSA 5039	LIVING QUARTERS ELIGIBILITY QUESTIONAIRE

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25	0	0	25	0	0
Annual Time Burden (Hours)	25	0	0	25	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $875

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/20/2023

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