Moving Expense Tax Form
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2University of Massachusetts Moving Expense Tax Form
I. Payments: Payment Description Amount Paid or reimbursed by the University of Massachusetts
A. Transportation and storage of household goods and personal effects
1.
2.
3.
4.
5.
6. Sub Total , Section A; lines 1 to 5
$
7. Portion on Part A Line 6 that was paid directly to vendors (3
party payments)
rd
8. Subtract Part A Line 6 from Part A Line 7 ( This amount will be reported on the employee’s W-2
in Box 13 with no tax withholdings)
$
B. Travel and lodging payments for expenses while moving from old to new home, no meals (show temporary living in item C.)
1. Auto mileage reimbursement at 27 cents per mile
2.
3.
4
5.
6. Sub Total Part I, Section B; lines 1 to 5
$
7. Portion on Section B Line 6 that was paid directly to vendors (3
party payments)
rd
8. Subtract Section B Line 6 from Section B Line 7 ( This amount will be reported on the
employee’s W-2 in Box 13 with no tax withholdings)
$
C. List of all other payments (specify)
1. Auto mileage reimbursement in excess of 27 cents per mile.
2. Temporary living expenses
3. House-hunting
4. All Meals, Food
5.
6.
7.
8. Total Section C; lines 1 to 5, Other Payments. This amount will be reported in the W-2 in Box 1
and the amount will be subject to payroll withholdings.
$
Total Payments
$
II. Does the move meet the 50 mile IRS test? _____ YES _____NO
III. Required Signatures
____________________________________
__________________________________ ___________________ _________
Employee's Signature
Employee's Name (please print)
Employee's ID#
Date
____________________________________
__________________________________
____________
Department Head’s Signature
Department Head’s Name (please print)
Date
____________________________________
_________________________________
___________
Vice Chancellor’s Signature
Vice Chancellor’s Name (please print)
Date
Controller’s Office Use Only Tax Year ____________ Employee SS#_______________ W-2 Box 1 (Subject to
Withholdings) $_____________ W-2 Box 12 $____________
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