Certified Statement Of Income And Tax Filing Status Extended Tdy Tax Reimbursement Allowance (Ettra) Form Page 2

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4. LOCAL TAX RETURNS. If you incurred 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
________________
______________
5. DECLARATION. The above information is true and accurate to the best of my (our)
knowledge. I (we) agree to notify the appropriate agency official of any significant changes to the
above so that appropriate adjustments to the ETTRA can be made.
Printed Name of Employee: _________________________________________
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 ETTRA. 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 ETTRA CLAIM:
a. Travel voucher (DD Form 1351-2), signed and dated, annotating ETTRA in the reimbursable
expense block
b. Travel orders (DD Form 1610 and all amendments)
c. All W-2s (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 ETTRA 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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