Certified Statement Of Income And Tax Filing Status Income Tax Reimbursement Allowance (Itra) Template Page 2

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LOCAL TAX RETURNS: If the employee incurs an additional local income tax liability as a
result of the long-term travel reimbursements, specify the name of the taxing locality(ies) and the
applicable tax rate(s), i.e., 1%, 2%, etc., for the tax year. If local tax rate is stated as a percentage of
federal or state income tax liability, such rate must be converted to a percent of taxable income.
LOCALITY
PERCENT
________________
______________
The preceding information is true and accurate to the best of my knowledge. I (we) agree to notify
the appropriate DoD component official of any changes to the above (i.e., from amended tax returns,
tax audits, etc.) so that appropriate adjustment to the ITRA allowance can be made. The required
supporting documents, including a signed and dated DD Form 1351-2 with my travel orders, all
claimed income (W-2s, etc.) and my Federal tax returns are attached. Additional documentation will
be furnished if required.
Employee’s Signature __________________________________ Date ___________________
Spouse’s Signature ____________________________________ Date ___________________
(If joint tax returns were filed for the year affected.)
Social Security Number _____________________
__________________________
Employee
Spouse (if applicable)
PRIVACY ACT STATEMENT
Collection of this information is authorized by 5 U.S.C. Section 5724b. The use of an individual’s
social security number for purposes related to Federal income taxes is authorized by 26 U.S.C.
Section 6109. The social security number will be used to verify the individual employee’s identity.
The information furnished or submitted with this form is confidential and will be used to calculate
the employee’s ITRA. Submission of the requested information is voluntary; however, failure to
provide the information listed on this form will make it impossible for DFAS-Rome to compute the
allowances.
ENSURE THE FOLLOWING DOCUMENTATION IS ATTACHED/INCLUDED WITH
THE SUBMISSION OF THE ITRA CLAIM:
a. Travel voucher (DD Form 1351-2), signed and dated, annotating ITRA in the reimbursable
expense block
b. Travel orders (DD Form 1610 and all amendments)
c. All W-2s, 1099-Rs for non-disability military retired pay and, if applicable, self-employment
income shown on attached Schedule SE (and spouse’s if filing a joint return)
d. Completed Federal income tax return (Form 1040) for the tax year in which the taxes were paid.
NOTE: In order to avoid processing delays, please ensure that the amount of income, as indicated
on this Certification Form, matches the income tax documentation submitted with the ITRA claim.
Failure to do so will result in your claim being returned without action until you provide a corrected
claim and/or additional documentation to support the claim.

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