Certified Statement Of Income And Tax Filing Status Relocation Income Tax Allowance (Rita) Template

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CERTIFIED STATEMENT OF INCOME AND TAX FILING STATUS
RELOCATION INCOME TAX ALLOWANCE (RITA)
I certify that the following information, which is to be used in calculating the RITA to which I am
entitled, has been shown on the income tax returns filed by me (or by my spouse and me) with the
applicable federal, state, and local (specify which) tax authorities for the ________ tax year.
1. INCOME. Gross compensation as shown on attached IRS Form(s) W-2, 1099-R(s) for non-
disability military retirement pay and, if applicable, net earnings (or loss) from self-employment
income shown on attached Schedule SE (Form 1040):
Military Retirement
Forms W-2
(Forms 1099-R)
Schedule SE
Employee
$ _____________
$ ____________
$ ______________
Spouse (if filing jointly)
$ _____________
$ ____________
$ ______________
TOTAL (all columns) $ ______________
Filing Status: ____________________________
(Specify the filing status that was claimed on IRS Form 1040; i.e., single, married filing jointly, etc.)
Printed Name of Employee: _________________________________________
2. STATE TAX RETURNS: In some circumstances, an employee may incur a state income tax
liability on moving expense reimbursements in more than one state. For example, an employee may
incur taxes on moving expense reimbursements in one state because of residency in that state, and in
another state because that particular state taxes income earned within its jurisdiction irrespective of
whether the employee is a resident.
The following state tax questions must be answered to determine the state marginal tax rate used
to compute the RITA. If you do not know the answers, please ask your tax preparer for
assistance.
A. Did more than one state tax your non-deductible moving expense reimbursements for the tax
year?
YES
NO
B. Did more than one state tax the same portion of your non-deductible moving expense
reimbursements for the tax year?
YES
NO
C. If two or more states taxed the same portion of your non-deductible moving expense
reimbursements, did either state allow for an adjustment or credit of other income taxes paid
to the other state?
YES
NO
D. List below the name of the state(s), if any, which taxed your non-deductible moving expense
reimbursements for the tax year.
STATE _____________________
STATE _____________________
E. Did a state treat a moving expense reimbursement as taxable even though that same expense is
nontaxable under federal tax rules?
YES
NO
March 2015

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