Form Rev-775 - Personal Income Tax Employee Business Expense Affidavit Page 2

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REV-775 (12-15)
PERSONAL INCOME TAX EMPLOYEE BUSINESS EXPENSE AFFIDAVIT
SECTION IV.
EXPENSE SUMMARY WORKSHEET
• Part - List the part of the PA Schedule UE where the expense was claimed.
• Line # - List the respective line from the PA Schedule UE where the expense was claimed.
• Claimed Expense Description - Provide a description of the item being claimed and provide the business related purpose.
• Claimed Expense Amount - Provide the amount of expense being
claimed.
Photocopied receipts are required to support the expenses claimed and all expenses must be clearly identified on the receipt(s).
CLAIMED
LINE
PART
CLAIMED EXPENSE DESCRIPTION
#
EXPENSE AMOUNT
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