Form Rev-775 (Ex) - Personal Income Tax Employee Business Expense Affidavit

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REV-775 (EX) 03-17

PERSONAL INCOME TAX

EMPLOYEE BUSINESS EXPENSE

AFFIDAVIT

BUREAU OF INDIVIDUAL TAXES

PO BOX 280501

HARRISBURG PA 17128-0501

Form REV-775 is to be used in the event that you are unable to provide a copy of your employer’s reimbursement policy or your employer refuses to provide

you and the Department of Revenue with either an employer letter or a completed REV-757.

SECTION I.

GENERAL INFORMATION

1. Name

SSN

Tax Year

START

2. Primary Taxpayer Name (Shown first on the PA-40)

Primary Taxpayer SSN (Shown first on the PA-40)

3. Employer Name

FEIN

4. Employer Contact

Contact Title

Contact Phone Number

SECTION II.

AFFIDAVIT

I hereby state that I am the person named above and have incurred employee business expenses as indicated on this form for the tax year shown above. I

also state that I am required to incur the employee business expenses in order to perform the duties and responsibilities of my position and that I am (please

check all that apply):

Not reimbursed in any manner for the expenses.

Reimbursed only for some of my expenses via a per-diem rate that is less than the federal per-diem expense rate or at a fixed amount and the

reimbursed expenses at these lower rates are not included on my PA Schedule UE nor claimed on my return.

Reimbursed in full for some of my expenses by my employer and the reimbursed expenses are not included on my PA Schedule UE nor claimed on my

return.

Signature

Date

MM/DD/YYYY

PLEASE SIGN AFTER PRINTING

Please notarize in the space below.

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