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)
Date (mm-dd-yyyy)
INSTRUCTIONS - Foreign Service Family Reserve Corps (FSFRC) Membership Recertification
FSFRC Coordinator Signature
Confirmation Sent to Employee
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); 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 certify continued eligibility in 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.
The last four digits of 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 Notice State-31, Human Resource Records and State-36,
Security Records.
DISCLOSURE: Disclosure of this information, including the last four digits of a Social Security Number, is voluntary. Failure to provide the information requested may result
in delays in recertifying eligibility.
Page 2 of 2
PURPOSE
The FSFRC Membership Recertification is used when requested by existing Department of State FSFRC Members in Reserve Status to certify their
continued eligibility for membership in the FSFRC.
Highlighted fields are mandatory.
• Enter your full name as reflected on your SF-50.
• Enter your Employee ID (found in box 44 on your SF-50) or the last four digits of your Social Security Number.
• Enter the post or domestic location mailing address (do not use a pouch address). This will be used for future correspondence via USPS mail for
those members without access to their eOPF.
• Enter your permanent personal contact email address. This should not be a state.gov email address as it will be used to contact you when you are
not actively working in a local assignment.
• Enter your personal phone number.
• Check-off the box that corresponds with your current security clearance or certification level.
• Provide your sponsoring employee's name.
• Provide your sponsoring employee's employing Agency.
• Enter your sponsoring employee's current post of assignment.
• Enter your sponsoring employee's Transfer Eligibility Date (TED).
• Enter your sponsoring employee's post of onward assignment.
• Enter your sponsoring employee's anticipated transfer date.
• Read each statement and initial those that apply to you.
• Read the membership agreement statement.
• Electronically sign and date.
• Required documentation for those members who initial statements c, d and/or e only.
• HR/SS Section to be completed by HR Shared Services only.
Submission Instructions: Completed recertification forms and required documentation may be submitted via email to FSFRC@state.gov .
Scanned forms cannot be accepted.
DS-5147
HR/SS USE ONLY
Date Received (mm-dd-yyyy)
Eligibility Requirements Met?
Yes
No
Confirmed FSFRC Category
1
2
3
Date Processed (mm-dd-yyyy) (If applicable)
Category 3:
ML
H
click to sign
signature
click to edit
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