Relocation Expense Authorization
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1
2STATE OF MINNESOTA
RELOCATION EXPENSE AUTHORIZATION
Agency/Department Name
Original
Expense Group ID
(MMB use only)
Revised (Revision #
)
Employee Name
Employee ID
Employee Record #
Employee Bargaining Unit Name
Bargaining Unit #
New Position #
Old Work Location
New Work Location
Total Miles One-way
Number of Dependents
Relocation Due To: Demotion
Promotion
Between Old & New
New State Employee
Layoff
Work Location
Relocation Period
Relocation Period
Travel Status
Travel Status
Begin Date
End Date
Begin Date
End Date
Expected Move Date
First Move? Yes
No
Total miles, one-way, between
Total miles, one-way, between
If no, when was your last move?
former home and old work
former home and new work
location.
location.
Agency Contact Name and Contact Address
Contact Telephone #
Expense Type
Max $ Amount within
Additional Information
Contract or Plan Limit
Miscellaneous Expenses
Travel Status Expenses
(temporary living expenses and pre-move expenses)
Moving Expense
(Paid by employee? _____ Paid by agency to third party? ______)
[Note: The agency can pay the moving company directly as long as the employee meets
the IRS time and distance tests. Refer to the instructions on page 2.]
Realtor's Fee
(selling home only)
Loan Origination Fee
(for purchase of home only) [Note: If the bargaining
agreement or compensation plan considers this fee to be a miscellaneous expense, please
include the amount in Miscellaneous Expenses (above).]
TOTAL AMOUNT APPROVED IS NOT TO EXCEED:
$0.00
Note: If the dates or amounts need to be changed, additional approval is necessary. Refer to the instructions on page 2.
I HAVE REVIEWED THIS FORM AND THE APPLICABLE BARGAINING AGREEMENT/COMPENSATION PLAN OR, FOR NEW EMPLOYEES, PERSONNEL
RULE 3900.2200 WHICH SPECIFIES THE RELOCATION TERMS AND CONDITIONS. I AM AWARE THAT SOME EXPENSES ARE TAXABLE. THEY WILL
BE ADDED TO MY WAGES FOR W-2 PURPOSES AND FEDERAL, STATE, AND FICA/MEDICARE TAXES WILL BE WITHHELD.
Date
Employee Signature
APPROVALS
I HAVE REVIEWED THIS FORM AND THE APPLICABLE BARGAINING AGREEMENT/COMPENSATION PLAN OR, FOR NEW EMPLOYEES, PERSONNEL
RULE 3900.2200 WHICH SPECIFIES THE RELOCATION TERMS AND CONDITIONS. I AGREE THAT THIS EMPLOYEE IS ELIGIBILE AND THAT THE
DATES AND AMOUNTS ON THIS FORM ARE IN COMPLIANCE WITH THE RELOCATION TERMS AND CONDITIONS OF THE APPLICABLE
AGREEMENT/PLAN/RULE.
Division Director
Date
Please send original to Minnesota Management &
Budget, Statewide Payroll Services, 658 Cedar St,
Ste 400, Saint Paul, MN 55155-1616. Distribute
copies to the employee, human resources/payroll
Accounting Director
Date
manager, and the accounting director.
Two (2) approvals are required, in addition to the
Agency Head or Designee
Date
employee signature.
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FI-00376-05 (06/13)
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