Form Rev-775 - Personal Income Tax Employee Business Expense Affidavit

Download a blank fillable Form Rev-775 - Personal Income Tax Employee Business Expense Affidavit in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Rev-775 - Personal Income Tax Employee Business Expense Affidavit with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

REV-775 (12-15)

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 pro-

vide 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 certify that I am the person named above incurring employee business expenses for the tax year shown above. I also affirm 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 reim-

bursed 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

SECTION III.

NOTARIZE