Form GSA 5039 GSA 5039 LIVING QUARTERS ELIGIBILITY QUESTIONAIRE

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LIVING QUARTERS ELIGIBILITY QUESTIONAIRE

OMB Control Number: XXXX-XXXX
Expiration Date: XX/XX/20XX

(See Privacy Act and Paperwork Reduction Act Statements on the back)
INSTRUCTIONS

Living quarters allowance (LQA) is provided to reimburse employees for suitable, adequate living quarters at posts where the
U.S. Government does not provide quarters. LQA may be used to pay for rent, utilities, taxes, and related fees (see the
Department of State Standardized Regulations at DSSR 130 for a complete listing).
LQA is a discretionary housing allowance granted to candidates recruited in the United States or outside the U.S. under
certain circumstances. It is not an entitlement.
Not all job candidates are eligible to receive LQA and not all existing LQA recipients are eligible for continuation of LQA upon
appointment to a different agency.
All applicants complete Section A. Members of the Uniformed Service complete Section B. Current civilian employees living
overseas must complete Section C.
Job candidates currently living in the Continental United States (CONUS), Alaska, Hawaii, or U.S. territories or
possessions do not have to complete this form.

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SECTION A - ALL JOB CANDIDATES
First Name

Middle Initial Email Address

Last Name

Postal Mailing Address

Permanent Address (if different)

Work Address

Federal Agency or Military Component

A

SECTION B - UNIFORMED SERVICES JOB CANDIDATES

(Attach a copy of your most recent DD-214 - Report of Transfer or Discharge)

Place of Entry into Current Active Home of Record at Time of Entry Station at the Time of
Discharge
into Active Service
Service
(Item 11b from DD-214)
(Item 23 from DD-214)
(Item 22 from DD-214)

Separation Date from
Uniformed Service
(Item 11b from DD-214)

Do you have Military Permanent Change of Station (PCS) orders, or other documentation, to demonstrate
an intent to return to the U.S?

YES

NO

Following the date of military separation, have you had other subsequent employers, such as local
employment or employment with U.S. firms (e.g., as a contractor)?

YES

NO

SECTION C - CIVILIAN JOB CANDIDATES
Date of First Arrival at Foreign Post (dd/mm/yyyy)

Expiration Date of Return Transport Agreement (dd/mm/yyyy)

F

Is your spouse or domestic partner a member of the uniformed services who is receiving a Basic Allowance
for Housing under the United States Code at 37 U.S.C. § 403 and/or an Overseas Housing Allowance
(37 U.S.C. § 405)?

YES

NO

What is the applicant’s actual place of residence in the United States? (Authority: DSSR 031.11)
City

County

State

For overseas applicants, if your current actual place of residence is in a foreign area, is that foreign residence fairly
attributable to only your work relationship with the U.S. Government (civilian or military) or is it due instead to personal
reasons? (Authority: DSSR 031.12a)
My foreign place of residence is fairly attributable only to my work with the U.S. Government.

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My foreign place of residence is instead primarily due to personal reasons.
GENERAL SERVICES ADMINISTRATION

GSA XXXX XX/20XX

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For overseas applicants, what type of employer did you previously have before applying to the position at GSA?
Check all that apply. (Authority: DSSR 031.12b)
The United States Government, including its Armed Forces;
A United States firm, organization, or interest;
An international organization in which the United States Government participates; or
A foreign government
For overseas applicants, while overseas, did you have a single employer or multiple employers?
Note: The U.S. Government is considered a single employer, military or civilian, regardless of transfers between
departments or agencies. (Authority: DSSR 031.12b, Footnote)
I had just one single employer while overseas.
I have had multiple employers while overseas (e.g., U.S. Government, a U.S. firm as a contract employee, appointment
to the United Nations, etc.)

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SECTION D - CHECKLIST OF REQUIRED DOCUMENTS
Retrieve the following documents and attach to this form. Check which documents are available below:
1. PCS Orders CONUS to Outside the Continental United States (OCONUS)
2. All Subsequent PCS Orders
3. DD-214 and/or Separation Location Memo (if Uniformed Services)
4. Retirement/Separation Orders (if Uniformed Services)
5. Transportation Agreement back to the U.S. (e.g. DD-1617)
6. DD-2367: Uniformed Services Overseas Housing Allowance
CERTIFICATION

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I certify the information provided above is true and accurate, to the best of my knowledge. I understand if I provide
information that is false I may be determined ineligible for LQA and may be indebted to the U.S. Government. I understand if
I fail to answer all of the above questions I may be denied eligibility to receive LQA.
Printed Name

Signature

Date

PRIVACY ACT STATEMENT
Collection of the information in this Direct Deposit Sign-Up Form is authorized by 5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and
Executive Order 9397 (November 22, 1943). Your social security number and the other information requested will allow the
Federal Government to process your direct deposit. Your social security number is requested to ensure the accurate
identification and retention of records pertaining to you and to distinguish you from other recipients of federal payments. This
information will be disclosed to the Department of the Treasury and its fiscal and financial agents, and other federal agencies,
as necessary to process your direct deposit. This information may also be disclosed to a court, congressional committee or
another government agency as authorized or required to verify your receipt of federal payments. Although providing the
requested information is voluntary, your direct deposit cannot be processed without it.

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PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and
Budget (OMB) control number. The OMB control number for this collection is XXXX-XXXX. We estimate that it will take XX
hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate,
including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General
Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

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GSA XXXX XX/20XX BACK