Fillable Form DS-1996 LIVING PATTERN QUESTIONNAIRE CIVILIAN POST ALLOWANCE MILITARY COLA

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Form DS-1996 LIVING PATTERN QUESTIONNAIRE CIVILIAN POST ALLOWANCE MILITARY COLA

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  • 39 check-boxes
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The US Department of State (DOS) or the State Department, is the government official division that advises the President and performs international relations. Equivalent to the outside service of different nations, it was built up in 1789 as the country's first official department.

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U.S. Department of State
LIVING PATTERN QUESTIONNAIRE (LPQ)
FOR CIVILIAN POST ALLOWANCE AND MILITARY COLA
Post/Duty Station:
1. Your Agency:
Department of Defense (Civilian)
Department of State
Agency for International Development
Other Agency (Please specify)
Department of Defense (Military)
(For the next two items, please select your pay schedule and pay grade - for example, FS-2, GS-7, E-4, WO-2, O-3.)
2. Your Pay Schedule:
FS (Foreign Service)
GS (Federal General Schedule)
SES (Federal Senior Executive Service)
Other (Please specify)
E (Military Enlisted)
WO (Military Warrant Officer)
O (Military Officer)
3. Your Pay Grade:
01
4. Number of family members at Post:
02 03
04
05 06 07 08 10
11
12
13
14
15
0
1 2 3 4
5
More than 5 (please specify):
5. Length of time at current location:
6. " I certify that the information I have provided on this Living Pattern Questionnaire is accurate to the best of my knowledge."
DS-1996
09-2007
The purpose of this questionnaire is to identify the consumer facilities and services that you and your family use at your post/duty station, as well as to
gather some other information about your living pattern that relates to the cost of living at your foreign location.The information you provide on this
questionnaire will be used to develop the Department of State's "Indexes of Living Costs Abroad." These indexes measure overall living cost differences
between Washington, D.C. and locations where federal employees are assigned abroad. The answers that you and others provide through this
questionnaire will be used, with other information, to establish your post (cost-of-living) allowance level. Please leave blank any question that
does not apply to you and your family. Accurate information is vitally important, so please take the time to complete the survey to the best of your ability.
Name (Print)
Signature
Date (mm-dd-yyyy)
Page 1 of 5
GENERAL INFORMATION
09
click to sign
signature
click to edit
Secondary Local Outlet
Consumer Goods and Services
Primary Local Outlet
Household Furnishings
Appliances (e.g., microwave & toaster)
Computer Accessories
Household Consumables (e.g., detergent and paper products)
Medical
Medicine (e.g., prescription, non-prescription)
Doctor (e.g., general practitioner and pediatrician)
Dentist
Hospital Facilities
Recreation
Audio/Visual (music CDs, DVD movies)
Photographic Supplies (film and developing photos/digital photos)
Reading Material (books, magazines)
Recreational Equipment (e.g., bicycle)
Movie Theater
Performing Arts
Sports Events
Public Transportation
Taxi
Meat and Dairy Products
Currency
7. Outlets. List the primary and secondary local outlets used by you and your family for each of the following consumer goods and services.
Do not include military facilities, the Embassy or Consulate commissary, or any other government owned or operated facilities.
CURRENCY: Enter local, USD or other country currency spent at that outlet.
Meat & Dairy Products:
Meat & Dairy Products:
Meat & Dairy Products:
Meat & Dairy Products:
Meats (beef, pork, lamb, poultry)
Fish, Fresh
Fish, Canned
Dairy Products (eggs, ice cream, milk, cheese)
Groceries
Groceries (bread, cereal, rice, pasta, drinks, baby food, other)
Fruits and Vegetables
Fresh Fruits and Vegetables
Canned Fruits and Vegetables
Frozen Vegetables
Alcohol and Tobacco
Wine
Whiskey (if different from wine)
Beer (if different from wine or whiskey)
Cigarettes
Clothing
Men's
Women's
Children's
Personal Care
Toiletries (e.g., toothpaste and shampoo)
Laundry/Dry Cleaning
Hair Services
Page 2 of 5DS-1996
Milk
Recreational Activities
Gym Membership
Pet Food
"Local Market" - items or services purchased locally regardless of the country of origin.
Personally Owned Vehicles
Meat & Dairy Products:
Meat & Dairy Products:
Meat & Dairy Products:
Meat & Dairy Products:
Gasoline
Auto Maintenance (oil change, tune-up)
Auto Parts (e.g., tires)
Household Help
Day Care (outside the home)
Food Away
Breakfast
Lunch
Dinner
Page 3 of 5DS-1996
8. Relative Importance of Various Sources of Supply (in %)
a. Please indicate in the table below, beside each subcategory of product, the average percentage of your household's shopping done at each type
of facility. The percentages summed across each row should add to 100%.
The subcategory definitions are as follow:
"Special Facilities" -items or services purchased at the embassy commissary or a US Military commissary or exchange if available for use.
"Subsequent Purchases".
Example:
Local
Market
(%)
Special Facilities
Embassy
Commissary
(%)
Military
Commissary
Exchange
(%)
Supply Brought
to Current
Location
(%)
Subsequent Purchases
U.S.
(Incl. catalogs/
Mail Order)
(%)
Other
Location
(%)
Total
(%)
50
blank
15
10 100%
blank
10
blank blank
100%
20
30
5
60
Toiletries
Household Consumables
Subcategory
7. Outlets (continued)
"Supply brought to current location" - items purchased in anticipation of your assignment or conveyed to the foreign location at U.S. government
expense in your household effects, unaccompanied or accompanied baggage.
b. Complete the following:
Local
Market
(%)
Special Facilities
Embassy
Commissary
(%)
Military
Commissary
Exchange
(%)
Supply
Brought to
Current
Location
(%)
Subsequent Purchases
U.S.(Incl.
Internet/Mail
Order
(%)
Other
Foreign
Location
(%)
Total
(%)
100 %
100 %
Meat (beef, pork, lamb, poultry)
Fresh Fish
Subcategory
Canned Fish
100 %
Dairy Products (eggs, cheese & ice cream)
100 %
Groceries
100 %
100 %
Breakfast
Canned Fruits/Vegetables/Juices
Fresh Fruits/Vegetables
100 %
"U.S." - Items purchased, after arrival, from a source in the U.S. (by internet, fax, mail order) or purchased during home leave/TDY/other visit in
the U.S.
"Other." - Items or services purchased from other posts or foreign locations (list names under number 9).
Performing Arts
Other
Foreign
Location
(%)
Supply Brought
to Current
Location
(%)
Local Market
(%)
Embassy
Commissary
(%)
Military
Commissary
Exchange
(%)
Total
(%)
Subcategory
Tobacco
100 %
Women's Clothing
100 %
Children's Clothing
100 %
Toiletries
100 %
Laundry/Dry Cleaning
100 %
Hair Services
100 %
Small Kitchen Appliances
100 %
Computer Accessories
100 %
Household Consumables
100 %
Medicine (non-prescription)
100 %
Dentist
100 %
Audio and Visual Supplies
Photographic Supplies
100 %
Reading Material
100 %
Movies (Marine House)
100 %
100 %
DS-1996 Page 4 of 5
8 b. Continuation
Men's Clothing
100 %
Special Facilities Subsequent Purchases
Sports Events
100 %
Gym Membership
100 %
Pet Food
100 %
Auto Maintenance
100 %
U.S.
(Incl. Internet/
Mail Order)
(%)
Frozen Vegetables
100 %
Alcoholic Beverages
100 %
9. If you indicated that you purchased from an "Other" foreign location, please identify the names of those retail sources below:
Doctor
100 %
100 %
Gasoline
100 %
Auto Parts (e.g., tires)
100 %
12. Dining: Estimate the percentage of your family's meals that are eaten
in each of the following facilities:
10. Relative Use of Commodities and Services. Approximate proportion of the following goods used in preparing meals at home (based on volume
only):
Fruits
Meats/Seafood
Vegetables
Fresh
%
%
Canned
%
TOTAL
100
Beef
%
%
Pork
Lamb
%
Poultry
%
Seafood
%
TOTAL
100
%
Fresh
%
Canned
%
Frozen
%
TOTAL
100
%
11. Transportation: Estimate the percentage of travel for which
you use each of the following forms of transportation:
Privately Owned Vehicle (POV)
%
Government Owned Vehicle (GOV)
%
Taxi
%
Municipal Bus
%
Subway/Commuter Train
%
TOTAL
100 %
Local Restaurants
Post Restaurant
Military Restaurant
Home
TOTAL
Breakfast
% %
%
% %
% %
%
%
%
Lunch Dinner
100 % 100 % 100 %
13. Special Arrangements:
Does the U.S. Government or landlord provide major furniture, such as beds, sofas, and tables?
Does the U.S. Government or landlord supply major household appliances such as stove,
refrigerator and washer/dryer?
Yes No
14. Household Help. If you employ household help, please complete the following:
Average Number Of Hours
Worked Per Week
Type of Household Help
Day Worker
Housekeeper
Cook
DS-1996 Page 5 of 5
%
%
Household Help necessary for:
Extra cleaning/laundry due to climate
Shopping/food preparation
Security
Language difficulties
Other (Please specify in comments)
15. Comments. Please provide a brief description of any significant cost-of-living expenses for your family not identified elsewhere on this questionnaire
(e.g., specific medical or educational expenses).
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Form DS-1996 LIVING PATTERN QUESTIONNAIRE CIVILIAN POST ALLOWANCE MILITARY COLA

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Completed 12 February 2020

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