First Middle Last
)
2. TRAVEL AUTHORIZATION NUMBER
3. OLD OFFICIAL STATION 4. NEW OFFICIAL STATION
5. DATE OF CLOSING OR SETTLEMENT
6. COMPLETE ADDRESS OF NEW RESIDENCE
(street, city, state, ZIP Code)
in lieu of GSA FORM 2494-A
INSTRUCTIONS TO EMPLOYEE: Total amount of expenses being claimed for the purchase of your home must be included on a
separate SF1012 Travel Voucher. This is strictly the itemization page. You must provide a copy of the Closing Disclosure
Document received at closing. (We will not accept the ALTA or Settle Statement forms.)
SECTION A - EMPLOYEE AND RESIDENCE INFORMATION
SECTION B - CLOSING COSTS CLAIMED
7. CLOSING COSTS CLAIMED AMOUNT
a. LOAN ORIGINATION FEE
b. APPRAISAL REPORT
c. CREDIT REPORT
d. LENDER'S INSPECTION FEE
f. SETTLEMENT OR CLOSING FEE
g. ABSTRACT OR TITLE SEARCH
h. TITLE INSURANCE BINDER
i. TITLE EXAMINATION
j. DOCUMENT PREPARATION
l. ATTORNEY'S FEE
NOTE: Only the lender's portion of a title insurance policy is reimbursable; if you
purchased both lender's and owner's coverage together, you should have the settlement agent provide
you with the proper proration of the cost.)
n. RECORDING FEES
o. CITY/COUNTY/TAX/STAMP
q. SURVEY
r. OTHER CLOSING COSTS (Identify)
2)
p. STATE TAX/STAMPS
CLAIM FOR REIMBURSEMENT OF CLOSING COSTS FOR PURCHASE OF NEW RESIDENCE
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, particularly sections 5721-5733, 30 USC 905 and Executive Order 9397. Disclosure of the data by you is voluntary. The principle 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 station
travel. Information may be transferred to appropriate Federal, State or local agencies when relevant to civil, criminal or regulatory investigations or
prosecutions. There is no personal liability to you if you do not furnish the requested information; however, we will not be able to reimburse you for your
expenses.
5)
6)
TOTAL CLOSING COSTS
3)
4)
