CERTIFIED STATEMENT OF INCOME AND TAX FILING STATUS

RELOCATION INCOME TAX ALLOWANCE (RITA)

(For relocations that reported to duty before 1/1/2015)

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 nondisability military retirement pay and, if applicable, net earnings (or loss) from self-employment 

income shown on attached Schedule SE (Form 1040):

Forms W-2

Military Retirement

(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

October 2015
3. 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

________________ ______________

4. DECLARATION. The preceding information is true and accurate to the best of my knowledge. 

I (we) agree to notify the appropriate DoD component official of any changes to the above (i.e., from 

amended tax returns, tax audits, etc.) so that appropriate adjustment to the RITA can be made. The 

required supporting documents, including a signed and dated DD Form 1351-2 with my travel orders 

and all claimed income (W-2s, etc.) are attached. Additional documentation will be furnished if 

required. 

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.)

Social Security Number _____________________ __________________________ 

 Employee Spouse (if applicable)

PRIVACY ACT STATEMENT

Collection of this information is authorized by 5 U.S.C. Section 5724b. The use of an individual’s 

social security number for purposes related to Federal income taxes is authorized by 26 U.S.C. 

Section 6109. The social security number will be used to verify the individual employee’s identity. 

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 for DFAS-Rome 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. W-2s, 1099-Rs for non-disability military retired pay and, if applicable, self-employment income 

shown on attached Schedule SE (and spouse’s if filing a joint return) 

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.