12. Special Circumstances (See Instructions)
FOREIGN SERVICE FAMILY RESERVE CORPS (FSFRC)
DECLINATION OF MEMBERSHIP
Do you fall into one of these categories? (Select one)
2. Applicant's Employee ID or Last 4 of SSN1. Applicant's Name (Last, First, MI) (As listed on SF-50)
4. Sponsoring Employee's Agency3. Sponsoring Employee's Name (Last, First, MI)
6. Current Mailing Address 7. Permanent Personal Email Address (Not state.gov)
8. Applicant's Last Day in Current Position (mm-dd-yyyy)
9. Current or Most Recent Post of Assignment 10. Current or Most Recent Position Held (As listed on SF-50)
CERTIFICATION
APPLICANT INFORMATION
13. Applicant's Signature (NOTE: Your signature must include /s/ before your typed name. Forms without the /s/
designation cannot be accepted for processing. Example: /s/Jane Doe.)
Date (mm-dd-yyyy)
DS-5137-D
09-2017
Page 1 of 2
HR/SS USE ONLY
14. Date Received (mm-dd-yyyy)
Date (mm-dd-yyyy)
17. FSFRC Coordinator Signature
15. Notification Mailed to Employee
16. Date SF-50 Processed (mm-dd-yyyy)
U.S. Department of State
If you answered "None of the above" to the question above, it is not necessary for you to submit a declination.
Fields highlighted yellow are mandatory. Email completed form to FSFRC@state.gov
11. Declination to Apply for Membership:
I have been informed of the opportunity to apply for membership in the Foreign Service Family Reserve Corps (FSFRC), and I hereby decline to
apply for such membership. I understand that by declining to apply for FSFRC membership, I will be required to resign from my current overseas
Family Member Appointment (FMA) or Temporary Appointment (TEMP) on or before my departure from Post, at which point my appointment will be
terminated, and I will not be placed in Intermittent-No-Work-Scheduled (INWS) status under FMA over-complement. By declining to apply for
membership, I understand that once the FSFRC hiring preference is implemented, I will not be eligible for an appointment under an FMA or TEMP
appointment for any overseas Department of State (DOS) positions. However, I will still be eligible to apply for employment with DOS or other
agencies under a Personal Services Agreement (PSA) or a Personal Service Contract (PSC), as appropriate. My decision to not apply for
membership in the FSFRC will not affect any Non-Competitive Eligibility (NCE) that I may have earned during my current or past employment under
an FMA or TEMP appointment.
5. Sponsoring Employee's Email Address
(Select)
click to sign
signature
click to edit
Page 2 of 2DS-5137-D
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Sections 303, 309, and 311 of the Foreign Service Act of 1980, as amended (Appointment and Hiring); and Section
201 of the Foreign Service Act of 1980, as amended (Management of the Foreign Service).
PURPOSE: The information collected in this form will be used to document your declination to apply for the Foreign Service Family Reserve Corps (FSFRC).
Social Security Numbers will be used to verify identity.
ROUTINE USES: The information on this form may be shared with a member of Congress in response to an inquiry made at your request or with law enforcement as
required by law. More information on the Routine Uses for the system can be found in System of Records Notice State-31, Human Resource Records.
DISCLOSURE: Disclosure of this information, including the Social Security Number, is voluntary. Failure to apply or decline membership in the FSFRC will result in
termination of employment.
AUTHORITIES: The information is sought pursuant to Sections 303, 309, and 311 of the Foreign Service Act of 1980, as amended (Appointment and Hiring); Executive
Order (E.O.) 13526, Sec. 5.4(d); E.O. 10450 (Security Requirements); E.O. 12968, Sections 3.3 and 2.1(b)(2); 5 C.F.R. § 731 (suitability); Homeland Security Presidential
Directive (HSPD-12) "Policy for a Common Identification Standard for Federal Employees and Contractors"; and Section 201 of the Foreign Service Act of 1980, as
amended (Management of the Foreign Service).
PURPOSE: The information collected in this form will be used to establish and maintain the Foreign Service Family Reserve Corps (FSFRC), to allow for the Department to
meet its need for a workforce capable of rapid assignment to positions overseas, including sensitive positions.
Social Security Numbers will be used to verify identity and to confirm existing security clearances.
ROUTINE USES: The information on this form may be shared with a member of Congress in response to an inquiry made at your request or with law enforcement as
required by law. More information on the Routine Uses for the system can be found in System of Records Notices State-31, Human Resource Records and State-36,
Security Records.
DISCLOSURE: Disclosure of this information, including the Social Security Number, is voluntary. Failure to provide the information requested on this form may result in
delays in considering an application or in an application not receiving full consideration for the position.
INSTRUCTIONS - Foreign Service Family Reserve Corps (FSFRC) Declination Form
PURPOSE
The FSFRC Declination Form is used by existing Department of State employees currently appointed under a Family Member Appointment or
Temporary Appointment, or currently in INWS status, to certify that they have been informed of their eligibility to apply for FSFRC membership but
are declining to do so.
Highlighted fields are mandatory.
1. Enter your full name as it appears on your SF-50.
2. Enter your Employee ID (found in box 44 on your SF-50) or the last four digits of your Social Security Number.
3. Provide your sponsoring employee's name.
4. Provide your sponsoring employee's employing Agency.
5. Enter your sponsoring employee's email address.
6. Enter your current or permanent domestic mailing address. Do not use a pouch address. This will be used for future correspondence through the
USPS.
7. Enter your permanent personal contact email address. This should not be a state.gov email address as it will be used for future correspondence.
You may wish to add FSFRC@state.gov to your email address book.
8. If applicable, enter your last day in your current position (mm-dd-yyyy).
9. Enter the post where you are currently residing or your most recent post of assignment if you are not currently overseas.
10. Enter your current or most recent position title (as found in either box 7 or 15 on your SF-50).
11. Read the declination statement.
12. Special Circumstances: Use this box to include information that may not be covered elsewhere on the form.
13. Sign and date the form. Your signature must include /s/ before your typed name. Forms without the /s/ designation cannot be accepted for
processing. Example: /s/Jane Doe.
14. The HR section is to be completed by HR Shared Services only.
Highlighted fields are mandatory.
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