Form 49631 - Employee Statement Of Employer Provided Vehicle Use 2000
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1EMPLOYEE STATEMENT OF EMPLOYER PROVIDED VEHICLE USE
(Annual Lease Value Method to be used with the Allowable Personal Use Policy)
State Form 49631 (2-00)
Prescribed by State Board of Accounts-2000
Your agency has developed a policy on the use of state vehicles. This policy was developed under the guidelines
established by the Internal Revenue Service. Please contact the payroll clerk or designated person in your agency for a
copy of the policy and instructions to be used in the preparation of this form.
SECTION 1
EMPLOYEE NAME __________________________________ AGENCY NUMBER _______
SOCIAL SECURITY NUMBER ______________________ PAY PERIOD ENDED ________
SECTION 2
If your agency policy is "Allowable-personal-use", then you need to select one of two methods used in computing the
compensation. The "Cents-per-mile method" will be the most commonly selected and is discussed on another form.
The "annual-lease-value" method can be used only when cents-per-mile cannot be used.
Employee must accumulate for each pay period the total mileage for business and personal. The information is entered
below:
___________________ + _____________________ = ________________________
Business miles
Personal miles
Total mileage
SECTION 3
I certify the above information is true and correct to the best of my knowledge. The necessary logs and documentation
are being kept and will be available for inspection by my agency, Auditor of State/designee and the Internal Revenue
Service.
Signatures: Employee ___________________________________ Date: _________________
Agency Director ___________________________________ Date: _________________
SECTION 4
To be completed by payroll clerk or agency designee.
___________________ / ____________________ = ____________________%
Personal miles
Total Mileage
Personal Usage
$_________________ x _____________________ = ____________________
Annual lease amount Personal usage % Annual value
from table usage
for personal usage
__________________ / 26 or 27 pay periods* = __________________
Annual value personal usage
Payroll amount
*Use number of pay periods for the current calendar year.
Signature of Preparer: ____________________________ Date: _____________________
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