Certified Statement Of Income And Tax Filing Status Income Tax Reimbursement Allowance (Itra) Template

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CERTIFIED STATEMENT OF INCOME AND TAX FILING STATUS
INCOME TAX REIMBURSEMENT ALLOWANCE (ITRA)
I certify that the following information, which is to be used in calculating the ITRA allowance to
which I am entitled, has been shown on the income tax returns filed by me (or by my spouse and
me) with the applicable federal, state, and local (specify which) tax authorities for the ________ tax
year.
Gross compensation as shown on attached IRS Form(s) W-2, 1099-R(s) for non-disability military
retirement pay and, if applicable, net earnings (or loss) from self-employment income shown on
attached Schedule SE (Form 1040):
Military Retirement
Forms W-2
(Forms 1099-R)
Schedule SE
Employee
$ _____________
$ ____________
$ _____________
Spouse (if filing jointly)
$ _____________
$ ____________
$ _____________
TOTAL (all columns) $ _____________
Filing Status: ____________________________
(Specify the filing status that was claimed on IRS Form 1040; i.e., single, married filing jointly, etc.)
Personal Exemptions (from IRS Form 1040) $ __________________________
Itemized or Standard Deductions (from IRS Form 1040 $ _________________
Printed Name of Employee: _________________________________________
STATE TAX RETURNS: In some circumstances, an employee may incur a state income tax
liability on long-term TDY expense reimbursements in more than one state. For example, an
employee may incur taxes on TDY expense reimbursements in one state because of residency in that
state, and in another state because that particular state taxes income earned within its jurisdiction
irrespective of whether the employee is a resident.
The following state tax questions must be answered to determine the state marginal tax rate used to
compute the ITRA. If you do not know the answers, please ask your tax preparer for assistance.
Did more than one state tax your long-term TDY expense reimbursements for the tax year?
YES
NO
Did more than one state tax the same portion of your long-term TDY expense reimbursements for
the tax year?
YES
NO
If two or more states taxed the same portion of your long-term TDY expense reimbursements, did
either state allow for an adjustment or credit of other income taxes paid to the other state?
YES
NO
List below the name of the state(s), if any, which taxed your long-term TDY expense
reimbursements for the tax year.
STATE _____________________
STATE _____________________

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