Employee Representation Regarding Use Of Company Vehicle Form

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EMPLOYEE REPRESENTATION REGARDING
USE OF COMPANY VEHICLE
The IRS requires employers to provide certain information on their tax return with respect to the vehicles provided to
employees. This information is also used to calculate the amount of the fringe benefit to be included in the employee’s Form
W-2 income.
The IRS generally requires that written records be maintained to document the business use of vehicles. Since the company
policy requires employees to maintain the detailed records, please provide answers to the following questions. If you were
provided more than one vehicle that was used during the year, you need to prepare a separate statement for each vehicle.
The completed form must be returned no later than _______ or 100% of the value of the use of the vehicle will be included in
your Form W-2 income.
(date)
Description of vehicle ___________________________________________
Reporting period from
to
Odometer reading:
Beginning _________
Ending _________
Employee Representation
(1)
Was the vehicle available for your personal use during off-
duty hours?
YES NO
(2)
Did you have another vehicle available for your personal use
(this includes a vehicle you own personally)?
YES NO
(3)
Are you an officer or 1% or more owner of the business?
YES NO
(4)
How many commuting round trips did you make in this
vehicle?
________________
(5)
For the reporting period specified above, please provide the
number of miles for each of the following categories:
Commuting miles
________________
Other personal (non-commuting) miles
________________
Total personal and commuting miles
________________
Total business miles
________________
(6)
Did the employer pay the cost of fuel consumed by this
vehicle?
YES NO
(EMPLOYEE SIGNATURE)
(DATE)

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