Applicant's Employee ID or Last 4 of SSNApplicant's Name (Last, First, MI) (As listed on SF-50)
MEMBER INFORMATION
Sponsoring Employee's AgencySponsoring Employee's Name (Last, First, MI)
Member's Current Mailing Address (Overseas or Domestic: City/State) Member's Personal Email Address (Not state.gov)
Member's Personal Phone
Current Security Clearance Certification Level (will be verified)
Top Secret (FSFRC Category 1)
Secret (FSFRC Category 2) Non-Sensitive (FSFRC Category 3)
MEMBERSHIP RECERTIFICATION
Initial all that apply. Do not use X or N/A. By initialing, I certify the following:
INITIALS
(a) I am a U.S.citizen
I am the spouse or domestic partner (as defined in 3 FAM 1610) of a sponsoring employee (i.e., a direct-hire Foreign Service, Civil
Service, or uniformed service member)
(b)
I am listed on the travel orders of a sponsoring employee for a post abroad at a U.S. mission under Chief of Mission authority, or at an
office of the American Institute in Taiwan (AIT), or assigned domestically, and
(c)
(d) I am listed on an approved Form OF-126 Foreign Service Residence and Dependency Report, or agency equivalent, of a sponsoring
employee, (see Required Attachments d)
(e) I am currently on approved Voluntary or Involuntary Separate Maintenance Allowance. (see Required Attachments e)
(f) I am currently employed under a Personal Services Agreement (PSA)
(g) I am currently employed under a Personal Services Contract (PSC), or as a third party government contractor
(h) I am a Civil Service employee of another agency (not DOS) CS employee in Leave Without Pay (LWOP) status.
Membership Agreement: I understand that I may resign my FSFRC membership at any time, and that my FSFRC appointment may be terminated at any time, regardless
of the expiration (Not to Exceed) date specified on the Notification of Personnel Action (SF-50), for reasons outlined in 3 FAM Termination of FSFRC Membership. I
understand that should I no longer meet the FSFRC eligibility criteria, or if my status as an Eligible Family Member should change, it is my responsibility to immediately
notify HR Shared Services at FSFRC@state.gov. As a member of the FSFRC, and while in Reserve Status, I am still a Department of State (DOS) employee even if not
working in a local or temporary assignment, and I am subject to standards of conduct and ethics requirements applicable to DOS employees. As a DOS employee, I am
subject to the reporting requirements found in 12 FAM 270 (Security Reporting Requirements) and 12 FAM 262 (Security Awareness and Contact Reporting).
Member 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)
Sponsoring Employee's Current Post of Assignment Transfer Eligibility Date (mm-dd-yyyy)
Sponsoring Employee's Onward Assignment (If known) Estimated Transfer/PCS Date (mm-dd-yyyy)
(i) I am currently, or will be within the coming year, residing at my sponsoring employee's post of assignment abroad (see Required
Attachment a or c), or
(ii) my sponsoring employee is currently assigned domestically and will not be returning overseas in the coming year, but intends to
return overseas in the future (see Required Attachments b or c)
Submission Instructions: Completed recertification forms and required documentation may be submitted via email to FSFRC@state.gov .
Fields highlighted yellow are mandatory.
DS-5147
09-2017
Page 1 of 2
U.S. Department of State
FOREIGN SERVICE FAMILY RESERVE CORPS (FSFRC)
MEMBERSHIP RECERTIFICATION
Required attachments. Please submit all attachments from list below that apply to your status for items checked in the Membership Recertification
statement section above.
(a) Sponsoring Employee's Travel Orders (TMFOUR) or TMONE Assignment Notification if TMFOUR not issued yet, or agency equivalent (see
Membership Recertification Statement c(i))
TMONE Change in TOD Memorandum (domestic assignment extensions) (see Membership Recertification Statement c(ii))(b)
For Members with a Non-DOS Sponsoring Employee: Written certification (official letter or memo) from the agency's Executive Office that the
sponsoring employee is expected to serve future tours at U.S. Missions overseas (see Membership Recertification Statement c(i))
(c)
(d) OF-126 Foreign Service Residence and Dependency Report or agency equivalent (see Membership Recertification Statement d). NOTE: This form is
only required if the applicant is not listed on their sponsoring employee's travel orders.
(e) VSMA or ISMA Bureau authorization cable (if applicable) (see Membership Recertification Statement e)
