Form Ia-22 Questionnaire Of Earnings Allocations
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1QUESTIONNAIRE OF EARNINGS ALLOCATIONS
A review of your return discloses that you lived and/or worked in more than one state during the tax year _____________.
Please complete this questionnaire for you and/or your spouse, in order that a proper allocation of income can be made on
your Kansas individual income tax return, and mail to: Kansas Department of Revenue, Correspondence, 915 SW
Harrison St. Topeka, Kansas 66612-1588.
1. Did you live in Kansas during tax period? Yes_____
No______
2. If married filing joint, did spouse live in Kansas during tax period? Yes_____
No______
If you answered “No” to question 1 and question 2, then stop here and mail form to the Kansas Department of Revenue
3. What dates were you a Kansas resident? From: ___ ___ ___ ___ ___ ___ to ___ ___ ___ ___ ___ ___
4. What dates was your spouse a Kansas resident? From: ___ ___ ___ ___ ___ ___ to ___ ___ ___ ___ ___ ___
5. List employers while a Kansas resident:
1. Employer Name_____________________________
a. Employer location (city and state)_____________________________________
b. Dates worked for this employer: From: ___ ___ ___ ___ ___ ___ to ___ ___ ___ ___ ___ ___
c. Total income earned from this employer: $______________
d. Income earned while living in Kansas: $ ______________
e. Name of person who worked for this employer (you or your spouse): ____________________
2. Employer Name_____________________________
a. Employer location (city and state)_____________________________________
b. Dates worked for this employer: From: ___ ___ ___ ___ ___ ___ to ___ ___ ___ ___ ___ ___
c. Total income earned from this employer: $______________
d. Income earned while living in Kansas: $ ______________
e. Name of person who worked for this employer (you or your spouse): ____________________
3. Employer Name_____________________________
a. Employer location (city and state)_____________________________________
b. Dates worked for this employer: From: ___ ___ ___ ___ ___ ___ to ___ ___ ___ ___ ___ ___
c. Total income earned from this employer: $______________
d. Income earned while living in Kansas: $ ______________
e. Name of person who worked for this employer (you or your spouse): ____________________
4. Employer Name_____________________________
a. Employer location (city and state)_____________________________________
b. Dates worked for this employer: From: ___ ___ ___ ___ ___ ___ to ___ ___ ___ ___ ___ ___
c. Total income earned from this employer: $______________
d. Income earned while living in Kansas: $ ______________
e. Name of person who worked for this employer (you or your spouse): ____________________
If you have more employers please complete and submit additional IA-22 form(s).
IA-22
(Rev. 8/07)
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