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
Subscribed and sworn before me this _______ day of ________________________ 20 _____.
PLEASE SIGN AFTER PRINTING
________________________________________________
________________________________________________
Signature of Notary Public
Seal
After notarizing the form, please complete a DEX-93, Personal Income Tax Fax Cover Sheet, and fax the completed form along with any other information
requested to the department at 717-783-5823.
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