| U.S. Treasury Department—Internal Revenue Service |

rom 2106 STATEMENT OF EMPLOYEE BUSINESS EXPENSES | 1961

| catendar yeor 161, o other taxable year hegtoning ————— 1961, and ending oe ss ne.

(ATTACH THIS STATEMENT TO YOUR INDIVIDUAL INCOME TAX RETURN)
If, as an employee, you were required to travel and incur business expenses, or to incur transportation, outside salesman or
education expenses during the taxable year, use of this form will help to determine your correct deduction for income tax
purposes. Include all expenses you paid or incurred as an employee, or expenses which you charged to your employer
(for example, through the use of credit cards), or expenses for which you received an advance, allowance, or reim-
bursement. For a more detailed explanation of these expenses, see page 4 of the instructions for Form 1040.

Your name ....

Address ._

Employer's name ..

Address ....

State occupation in which expenses were incurred 7 _
A. Employee business expenses which are deductible in computing total income (line 9, page 1 of Form 1040).
1, Travel expenses while away from home on business: (Number of days___)
(a) Railroad, airplane, boat, etc., fares.
(b) Meals and lodging... . .
(c) Automobile expenses (from Schedule A)

(ad) Other travel expenses (specify) -..

Total travel expenses........ : fees
2. Local transportation expenses (not between home and work):
(a) Local bus, street car, and taxi fares...... 66.0.0... e ee eee

(b) Automobile expenses (from Schedule A)
(c) Other (specify)

Total local transportation expenses

3. Outside salesmen’s expenses:
(a) Automobile expenses (from Schedule A).
(b) Other (specify)

Total outside salemen’s expenses.
4, Total of lines 1, 2, and3....... bev e eect ee ees
Less: Amount of employer's payments for above expenses bocce veeee es
6. Excess expenses (line 4 less line 5) $ , or excess employer payments (line 5 less line 4) $.

-$

a

Deduct excess expenses from salary, wages, etc., before entering that income on line 1, page 1, Form

1040.

Report excess employer payments on line 1, page 1, Form 1040 as “Excess Reimbursements.”’

B. Employee business expenses which are deductible if you itemize deductions on page 2 of Form 1040.

1, Business expenses other than those included above (specify) -........--

eee eve ee eee eee &

2. Total... eee. e eee ere
3. Less: Amount of employer's payments for these expenses cence . . see bee
4, Excess expenses (line 2 less line 3) $_____, or excess employer payments (line 3 less line 2) $

If you itemize your deductions, rather than elect to use the standard deduction, deduct excess expenses
under ‘‘Other Deductions” on page 2 of Form 1040.

Report excess employer payments on line 1, page 1, Form 1040 as ‘Excess Reimbursements.””



SCHEDULE A—AUTOMOBILE EXPENSES

1, Gasoline, oil, lubrication, etc... $. —
2. Repairs
3, Tires, supplies, ete... cccceceeee

=

. Other (specify) ..

Total ...

2

. Total mileage during year .

a

. Portion applicable to business

2

Percentage of expense applicable to busi-
ness (line 7 divided by line 6)...........

9. Business portion (line 5 multiplied by line 8) $-..
10. Depreciation from Schedule C, col. (h)
11. *Total deductible automobile expenses... $.

* Allocate to appropriate sections of Item A on page 1.

i SCHEDULE B—COMPUTATION OF AUTOMOBILE BASIS

Note.—If the vehicle was acquired for cash only or by trade-in ot
another vehicle which was not used in business, complete only lines 8
through 13 below. If acquired by trade-in of another vehicle
previously used in’ business, complete lines 1 through 13. (The
basis for depreciation must be recomputed each succeeding year it
the percentage of business use changes.)

Old Car Traded-In

1. (a) Total mileage accumulated

() Portion applicable to business coeceeeeeee miles
(c) Percentage applicable to business (line
(b) divided by line (a)) ce —-%

2. Purchase price or other basis $
3. Less: Trade-in allowance
4. Difference (line 2 less line 3) $.

5. Line 4 multip
1 (°)

lied by percentage on line
c becuse

6. Depreciation allowed or allowable

7. Gain (line 6 less une 3) or loss (line 5 less
line 6) on business portion of car

Present Car

8. Purchase price or other basis

9. Less: Estimated salvage value. (Estimated
resale or trade-in value of vehicle deter-
mined at time of purchase) -

10. Balance (line 8 less line 9)

11. Line 10 multiplied by
8 of Schedule A. .

12. Less: Gain (or plus loss) on line 7 above

13. BASIS for computing depreciation $.
SCHEDULE C—DEPRECIATION OF AUTOMOBILE
i Date Basis (From line 13 ‘Age whi | Depreciation allowed ir Method of computin, Rate (%) Depreciation deductible
Make and style of vehice acquited Se" Maule | meer yearn” | Me feprecation © | orlife years) | for this Jear
@ () © @ ) a @) jt

|

|
|
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SCHEDULE D—ADDITIONAL INFORMATION TG BE FURNISHED BY PERSONS CLAIMING A DEDUCTION FOR

EDUCATIO!

IN EXPENSES

1. Name and address of educational institution or activity ~

. Was the edi:cation undertaken in order for

statement from your employer to this effect.

the courses taken and your employment during the period

Is it customary for other members of your trad
.. List the principal subjects you studied at the educational institution

you to retain your em

le or profession to undertake similar education? [] Yes L] No.

ployment, salary, or status? L] Yes [1] No.

. If your answer to question 2 is “No,” state the primary purpose of obtaining the additional education and show the relationship between

shown in question 1 above or describe your educational activity —

5. If you were a candidate for a degree, what is the degree?

US. GOVERNMENT PRI

NTING OFFICE = 1962 0—629620