Certified Statement Of Income And Tax Filing Status Extended Tdy Tax Reimbursement Allowance (Ettra) Form

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CERTIFIED STATEMENT OF INCOME AND TAX FILING STATUS
Extended TDY Tax Reimbursement Allowance (ETTRA)
(For travel which began on or after 1/1/2015)
An ETTRA is designed to reimburse an employee for substantially all of the income taxes incurred
as a result of a taxable extended TDY assignment.
The following information, which my agency will use in calculating the ETTRA to which I am
entitled, was shown on the Federal, state and local income tax returns that I (or my spouse and I)
filed for the 20_____ tax year.
1. FEDERAL FILING STATUS. As shown on my (our) IRS Form 1040:
Single
Head of Household
Married Filing Jointly
Qualifying Widow(er)
Married Filing Separately
2. TAXABLE INCOME. As shown on my (our) IRS Form 1040 after personal exemptions and
itemized/standard deductions are subtracted:
$ ________________
3. 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 ETTRA. If you do not know the answers, please ask your tax preparer for
assistance.
A. Did more than one state tax your long-term TDY expense reimbursements for the tax year?
YES
NO
B. Did more than one state tax the same portion of your long-term TDY expense reimbursements
for the tax year?
YES
NO
C. 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
D. List below the name of the state(s), if any, which taxed your long-term TDY expense
reimbursements for the tax year.
STATE _____________________
STATE _____________________
October 2015

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