Relocation Income Tax Allowance (RITA)

• Legal Form Number: BP-A0642
• Date: 2010-06
• Year: 2010
• Section: Federal Bureau of Prisons

RELOCATION INCOME TAX ALLOWANCE (RITA) CERTIFICATION U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A0642

JUN 10

Name:

Address:

Work

Phone #:

Home

Soc. Sec. #:

Transfer Date:

I certify that the following information, which is to be used in calculating the RITA for which I am entitled, has been (or will be shown on the income tax

returns filed (or to be filed) by me (or by my spouse and me) with the applicable Federal, State and local tax authorities for tax year .

FILING STATUS

Single

Married Filing

Joint Return

Head of Household

Married Filing

Separate Return

GROSS COMPENSATION

*from Form(s) W-2 (including Relocation) and/or net earnings on Schedule SE (only applicable for self-employment)

Forms W-2

Line 1 + Line 2

Schedule SE

Spouse (if filing joint return)

Employee $ $

$$

TOTAL $

LOCALITY TAX

Do you pay a locality tax (city or county income tax)?

If so, what is the tax rate?

Is the tax a percentage of

%

income? state tax? or federal tax?

* If you received relocation reimbursements for two moves

during this tax year, please list the cities and states to which

you relocated.

* From your old residence, is the distance to your new duty

station at least 35 miles greater than the distance to your old

1st Move

2nd Move

The above information is true and accurate to the best of my knowledge. I/we agree to notify Relocation Services of any changes to the above (i.e.,

from the amended tax returns, tax audit, etc.) so that appropriate adjustment to the RITA may be made. Additional documentation will be furnished

upon request.

Employee's Signature

Spouse's Signature (if filling joint return)

Date

Date

*Please be sure that all W-2 forms and Schedules (if applicable) are attached.

duty station?

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