CERTIFIED STATEMENT OF INCOME AND TAX FILING STATUS

RELOCATION INCOME TAX ALLOWANCE (RITA)

The following information, which my agency will use in calculating the RITA to which I am entitled, 

was shown on the Federal, state and local income tax returns that I (or my spouse and I) filed for the 

20_____ tax year. 

1. FEDERAL FILING STATUS. As shown on my (our) IRS Form 1040:

Single Head of Household

Married Filing Jointly Qualifying Widow(er)

Married Filing Separately

2. TAXABLE INCOME. As shown on my (our) IRS Form 1040 after personal exemptions and

itemized/standard deductions are subtracted:

$ ________________ 

3. 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

July 2020
4. LOCAL TAX RETURNS. If you incurred an additional local income tax liability as a result of

moving expense reimbursements, specify the name of the taxing locality(ies) and the applicable tax

rate(s), i.e., 1%, 2%, etc., for the tax year. If local tax rate is stated as a percentage of federal or state

income tax liability, such rate must be converted to a percent of taxable income.

LOCALITY PERCENT

________________ ______________

5. DECLARATION. The above information is true and accurate to the best of my (our) knowledge.

I (we) agree to notify the appropriate agency official of any significant changes to the above so that

appropriate adjustments to the RITA can be made.

I (we) further agree that if the 12-month service agreement required by 41 CFR 302-2.15 is violated, 

the total amount of the RITA will become a debt due the United States Government and will be repaid 

according to agency procedures. 

Employee’s Signature Date 

Spouse’s Signature Date 

(If joint tax returns were filed for the year affected.)

PRIVACY ACT STATEMENT

Collection of this information is authorized by 5 U.S.C. Section 5724b. The information furnished or 

submitted with this form is confidential and will be used to calculate the employee’s RITA. 

Submission of the requested information is voluntary; however, failure to provide the information 

listed on this form will make it impossible to compute the allowances. 

ENSURE THE FOLLOWING DOCUMENTATION IS INCLUDED WITH THE CLAIM:

a. Travel voucher (DD Form 1351-2), signed and dated, annotated as “RITA”

b. Travel orders (DD Form 1614 and all amendments)

c. All W-2s (to include spouse’s if filing jointly)

d. Completed Federal income tax return (Form 1040) for the year in which the taxes were paid.

NOTE: In order to avoid processing delays, please ensure that the amount of income, as indicated on 

this Certification Form, matches the income tax documentation submitted with the RITA claim. 

Failure to do so will result in your claim being returned without action until you provide a corrected 

claim and/or additional documentation to support the claim.