PDF document

- 1 -

                                    (EX) 02-22 (FI)

                   REV-775                            PERSONAL INCOME TAX 
                   BUREAU OF INDIVIDUAL TAXES 
                   PO BOX 280501                      EMPLOYEE BUSINESS 
                   HARRISBURG PA  17128-0501          EXPENSE AFFIDAVIT

 Form REV-775 is to be used in the event that you are unable to provide a copy of your employer’s reimbursement policy or your employer 
 refuses to provide you and the Department of Revenue with either an employer letter or a completed REV-757.
      SECTION I        GENERAL INFORMATION
START  1. Name                                                               SSN                             Tax Year
Ü
  2. Primary Taxpayer Name (Shown first on the PA-40)                        Primary Taxpayer SSN (Shown first on the PA-40)

  3. Employer Name                                                           FEIN

  4. Employer Contact                                  Contact Title              Contact Phone Number

      SECTION II       AFFIDAVIT
 I hereby state that I am the person named above and have incurred employee business expenses as indicated on this form for the tax 
 year shown above. I also state that I am required to incur the employee business expenses in order to perform the duties and 
 responsibilities of my position and that I am (please mark all that apply):
      Not reimbursed in any manner for the expenses.

      Reimbursed only for some of my expenses via a per-diem rate that is less than the federal per-diem expense rate or at a 
      fixed amount and the reimbursed expenses at these lower rates are not included on my PA Schedule UE nor claimed on my return.
      Reimbursed in full for some of my expenses by my employer and the reimbursed expenses are not included on my PA Schedule 
      UE nor claimed on my return. 

  Signature                                                                                 Date            MM/DD/YYYY
                      PLEASE SIGN AFTER PRINTING

 Please notarize in the space below.

 Reset Entire Form    TOP OF PAGE                                                NEXT PAGE                  PRINT

- 2 -

                    REV-775 (EX) 02-22 (FI)

 SECTION III         EXPENSE SUMMARY WORKSHEET

          •  Section - List the section of the PA Schedule UE where the expense was claimed. 
          •  Line # - List the respective line from the PA Schedule UE where the expense was claimed. 
          •  Claimed Expense Description - Provide a description of the item being claimed and provide the business related purpose.  
          •  Claimed Expense Amount - Provide the amount of expense being claimed. 
 
Photocopied receipts are required to support the expenses claimed and all expenses must be clearly identified on the receipt(s).

                                                                                                       CLAIMED  
SECTION LINE #                             CLAIMED EXPENSE DESCRIPTION
                                                                                                       EXPENSE AMOUNT

Reset Entire Form   PREVIOUS PAGE                                                            NEXT PAGE PRINT

- 3 -

Instructions for REV-775
REV-775 IN (EX) 02-22 Personal Income Tax Employee Business Expense Affidavit

BLOCK 4
GENERAL INFORMATION
Provide the name of a contact within your employer’s
Please remember that for an expense to be allowable, it human resource, payroll or accounting office; including
must meet all of the following conditions: their title and phone number. So we have a point of contact
to affirm any assertions being made.
1. The actual amount paid must be reported. Expenses
may not be estimated, guessed or calculated using fed- SECTION II
eral per diem rates.
Complete the appropriate information on the affidavit, sign
2. The expenses must be reasonable. The amount of the form, and have the document notarized by a licensed
expenses should not be excessive in relation to Notary Public.
income, type of expenditure or purpose of expense.
SECTION III
3. The expenses must be necessary and a condition of
employment. Expenses cannot be incurred to make the To expedite the processing of your income tax return, pro-
job more convenient or productive. vide a detailed listing of your expenses and photocopies of
any original expense documentation with the submission of
4. Only ordinary expenses are allowable. The expenses
your affidavit. (See Expense Summary Worksheet for an
must be similar to those incurred by other employees in example.)
the same trade or profession.
NOTE: Please do not send original receipts to the
5. The expenses must be directly related to the employ- department as they will not be returned and should
ee’s present trade, business or profession. Expenses be retained for your records.
from a previous job or incurred for a future occupation
OPTIONS FOR PROVIDING THE INFORMATION
may not be taken as Unreimbursed Expenses.
You may email, fax or mail the form and documentation to
6. The expenses must be unreimbursed. the department. When emailing the form and documenta-
tion, use a DEX-93, Personal Income Tax Correspondence
SECTION I Sheet and email the information to RA-BITPITHOLDCOR-

FAXE@PA.GOV. When faxing the form and documenta-
BLOCK 1 tion, use a DEX-93, Personal Income Tax Correspondence
Provide the required information for the taxpayer (employ- Sheet and fax the information to 717-783-5823. When mail-
ee) claiming the business expenses. ing the form and documentation, mail it to the department
at:
BLOCK 2
PENNSYLVANIA DEPARTMENT OF REVENUE
Provide the required information for the primary taxpayer
PO BOX 280501
listed on the PA-40. HARRISBURG PA 17128-0501
BLOCK 3 NOTE: Emailing or faxing the form and documenta-
Provide the employer’s name and federal employer identi- tion to the department will reduce the processing time
fication number. of your return.

www.revenue.pa.gov REV-775 1
Reset Entire Form PREVIOUS PAGE PRINT

PDF file checksum: 1883501289

(Plugin #1/9.12/13.0)