Pennsylvania Personal Income Tax Employee Business Expense Affidavit

Personal Income Tax Employee Business Expense Affidavit
Personal Income Tax Employee Business Expense Affidavit (REV-775)
(EX) 02-22 (FI)

REV-775

BUREAU OF INDIVIDUAL TAXES
PO BOX 280501
HARRISBURG PA 17128-0501

PERSONAL INCOME TAX
EMPLOYEE BUSINESS
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

➜
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

SECTION II

Contact Title

Contact Phone Number

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

PLEASE SIGN AFTER PRINTING

MM/DD/YYYY

Please notarize in the space below.

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

SECTION III
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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).

SECTION LINE #

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CLAIMED
EXPENSE AMOUNT

CLAIMED EXPENSE DESCRIPTION

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Instructions for REV-775

Personal Income Tax Employee Business Expense Affidavit

REV-775 IN (EX) 02-22

GENERAL INFORMATION
Please remember that for an expense to be allowable, it
must meet all of the following conditions:
1. The actual amount paid must be reported. Expenses
may not be estimated, guessed or calculated using federal per diem rates.
2. The expenses must be reasonable. The amount of
expenses should not be excessive in relation to
income, type of expenditure or purpose of expense.
3. The expenses must be necessary and a condition of
employment. Expenses cannot be incurred to make the
job more convenient or productive.
4. Only ordinary expenses are allowable. The expenses
must be similar to those incurred by other employees in
the same trade or profession.
5. The expenses must be directly related to the employee’s present trade, business or profession. Expenses
from a previous job or incurred for a future occupation
may not be taken as Unreimbursed Expenses.
6. The expenses must be unreimbursed.

SECTION I
BLOCK 1
Provide the required information for the taxpayer (employee) claiming the business expenses.
BLOCK 2
Provide the required information for the primary taxpayer
listed on the PA-40.
BLOCK 3
Provide the employer’s name and federal employer identification number.

www.revenue.pa.gov
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BLOCK 4
Provide the name of a contact within your employer’s
human resource, payroll or accounting office; including
their title and phone number. So we have a point of contact
to affirm any assertions being made.

SECTION II
Complete the appropriate information on the affidavit, sign
the form, and have the document notarized by a licensed
Notary Public.

SECTION III
To expedite the processing of your income tax return, provide a detailed listing of your expenses and photocopies of
any original expense documentation with the submission of
your affidavit. (See Expense Summary Worksheet for an
example.)
NOTE: Please do not send original receipts to the
department as they will not be returned and should
be retained for your records.
OPTIONS FOR PROVIDING THE INFORMATION
You may email, fax or mail the form and documentation to
the department. When emailing the form and documentation, use a DEX-93, Personal Income Tax Correspondence
Sheet and email the information to [email protected]. When faxing the form and documentation, use a DEX-93, Personal Income Tax Correspondence
Sheet and fax the information to 717-783-5823. When mailing the form and documentation, mail it to the department
at:
PENNSYLVANIA DEPARTMENT OF REVENUE
PO BOX 280501
HARRISBURG PA 17128-0501
NOTE: Emailing or faxing the form and documentation to the department will reduce the processing time
of your return.

REV-775

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