Permanent Resident Form - Millenia Medical Staffing printable pdf download

PERMANENT RESIDENT FORM

The IRS requires that you pay taxes on travel expense reimbursement and housing benefits unless you are maintaining a permanent

residence while on assignment with us. This form will provide us with needed information about your permanent residence. If you

DO NOT return this completed from to us, or if you do not meet the permanent residence criteria, the IRS requires that we

treat your travel and housing benefits as income and withhold taxes accordingly.

To determine whether you maintain a permanent residence, the following IRS requirements must be met:

1. Generally, you must meet the following criteria:

a. You do some work in the area of the principle residence and stay at the residence while working in the area..

b. You have duplicate living expenses when away from the residence of business.

c. You have not abandoned the residence (e.g., your family lives there.)

2. There must be a realistic expectation that you will return to live at your claimed tax home.

Please complete the form and return it to us as soon as possible. Failure to return this form will require that we treat

travel and housing benefits as income and will withhold taxes accordingly.

1. Name: __________________________________________ SSN: _______________________________

2. Permanent Address: ___________________________________________________________________

Street

City

State

Zip

Telephone: ______-________-_______

3. Temporary Address while on assignment:

____________________________________________________________________________________

Street

City

State

Zip

Temporary Phone: _______-_________-____________

4. Are you registered to vote? Yes No (circle one)

County/State: ___________________________

5. Do you expect to return to your community of permanent residence? Yes No (circle one)

6. Do you sometimes do work in the area of the permanent residence?

Yes No (circle one)

7. Where do you file your state and local taxes? ______________________________________________

8. Do you own or rent your own residence?

Yes No (circle one)

a. If yes, will you continue to maintain this residence? Yes No (circle one)

b. Do you anticipate leaving personal effects (i.e. furniture, business records and papers) at this

residence?

Yes No (circle one)

9. In what city do you have your bank accounts? ______________________________________________

Will you maintain your account there?

Yes No (circle one)

10. Do you have family, financial or social ties with your community of permanent residence?

Yes No (circle one)

11. In what state do you current driver’s license? _____________________________________________

12. If you own a car, in what state is it registered? ____________________________________________

It is the responsibility of the employee to contact Millenia Medical Staffing when your permanent residence

status changes.

I, the undersigned, understand the above information and have communicated all questions with Millenia

Medical Staffing.

Print Name: __________________________________________________________________________

Signature: _______________________________________ Date: ____________________________

Permanent Resident Form - Millenia Medical Staffing

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