Form 49632 - Employee Statement Of Employer Provided Vehicle Use January 2001
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1EMPLOYEE STATEMENT OF EMPLOYER PROVIDED VEHICLE USE
(Daily Commuting and Cents Per Mile Methods)
State Form 49632 (R / 1-01)
Prescribed by State Board of Accounts-2001
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
Agency policy is “Commuting-use-only” then the following computation is to be used:
_________________ x $1.50 = _________________
Number of one-way
Value of benefit in
commutes
current pay period
NOTE:
The certificate must be signed at the bottom of this form.
SECTION 3
If agency policy is “Allowable-personal-use”, then two methods of computing the taxable income exist, “cents-per-
mile” and “annual lease-value”. Below is the “cents-per-mile” computation since it is the most common. The
“annual lease value computation” is on a separate form.
(A) ___________________ x $0.345 = $________________
Personal mileage driven
Adjustment if fuel is personally purchased:
(B) ___________________ x $0.055 = $________________
(C) Value of benefit in current pay period (A-B) = $________________
NOTE:
You cannot use the vehicle cents-per-mile rule for a vehicle first made available to an employee
for personal use (including commuting) in 2000 if the fair market value is more than $15,400.
NOTE:
The certificate must be signed at the bottom of this form.
CERTIFICATE
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: ______________________________
NOTE: Above rates and amounts subject to change by IRS.
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