1. EMPLOYEE NAME (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 Old RESIDENCE
(street, city, state, ZIP Code)
in lieu of GSA FORM 2494
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.
PRIVACY ACT OF 1974
CLAIM FOR REIMBURSEMENT OF CLOSING COSTS FOR SALE OF OLD RESIDENCE
5)
6)
TOTAL CLOSING COSTS
3)
4)
1)
2)
l. STATE TAX/STAMPS
m. PEST INSPECTION
n OTHER CLOSING COSTS (Identify)
k. CITY/COUNTY/TAX/STAMP
i. TITLE INSURANCE
j. RECORDING FEES
d. TITLE INSURANCE BINDER
e. TITLE EXAMINATION
f. DOCUMENT PREPARATION
g. NOTARY FEES
h. ATTORNEY'S FEE
SECTION B - CLOSING COSTS CLAIMED
a. SALES/BROKER COMMISION
b. SETTLEMENT OR CLOSING FEE
c. ABSTRACT OR TITLE SEARCH
INSTRUCTIONS TO EMPLOYEE: Total amount of expenses being claimed for the sale 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 form).
SECTION A - EMPLOYEE AND RESIDENCE INFORMATION
