HENNEPIN COUNTY
PRINCIPAL PLACE OF BUSINESS DESIGNATION FORM
(For internal County use only)
2/2008
Purpose of principal place of business designation: If an employee’s home office has been designated as his/her principal
place of business, that employee is eligible to be fully reimbursed for business-related mileage costs including those incurred
from traveling distances between the employee’s home and the first and last work-related destinations in the work day. An
employee with such designation will request reimbursement using the standard Mileage & Parking Reimbursement Request
Form (HC 489A).
Instructions: File one completed copy of this form with both the Accounts Payable Supervisor in the Office of Budget &
Finance (mail code 131) and with the finance/accounting and/or payroll area of the employee's department. See Hennepin
County Administrative Manual: Mileage And Parking Reimbursement Policy for more information. This form must be
renewed annually by February 1st.
Employee’s Name: ____________________________________________ Job class: _______________________________
Work Unit/Division and Department: _______________________________________________________________________
PART A: WORKPLACE ANALYSIS
To be completed by manager in consultation with supervisor and employee
1) Has Hennepin County specifically designated an office for this employee at a County facility?
YES / NO
If yes, STOP, the employee’s home cannot be designated as a “principal place of business”.
2) Check office equipment and supplies provided by the County for the employee’s use at his/her home:
________ Computer
________ Desk/chair
________ Telephone
________ Filing cabinet(s)
________ Internet access
________ Office supplies
________ Other
________ Other
________ Other
3) Mark the work activities the employee performs, the location of the work activity, and the percentage of time spent on each
work activity in a typical 2-week work period.
LOCATION
% OF
PERFORMED
WORK TIME
Primary work activity (e.g., client and client-related contacts)
____________
____________
Work administration and documentation (e.g., case
notes, charting, form completion, filing)
____________
____________
Work-related communications (e.g., phone, e-mail)
____________
____________
Meetings with supervisor and/or team
____________
____________
Other: _____________________________________________
____________
____________
Other: _____________________________________________
____________
____________
TOTAL:
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100%
HENNEPIN COUNTY
PRINCIPAL PLACE OF BUSINESS DESIGNATION FORM
(For internal County use only)
2/2008
I have reviewed the information presented and determined that it is for the convenience of Hennepin County that the principal
place of business for the above-named employee is located at the employee’s home.
Manager: _________________________________________________________________________ Date: _____________
COMMENTS: ________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PART B: COUNTY DESIGNATION
To be completed by Department Director or Designee
I have reviewed the information presented and determined that it is for the convenience of Hennepin County that the principal
place of business for the above-named employee is located at the employee’s home.
Department Director (or Designee): ______________________________________________ Date: ____________________
COMMENTS: ________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PART C: EMPLOYEE ACNKOWLEDGEMENT
Employee Acknowledgement
I hereby acknowledge that Hennepin County has designated my home as my principal place of business and that such
designation is at the sole discretion and for the convenience of Hennepin County. I understand that Hennepin County may
change this designation at its choosing. I also understand that Hennepin County makes no representations as to the tax status
or implications of such a designation for my personal income taxes. I agree to maintain the security of all county records, data,
equipment, and supplies used in my home in accordance with relevant law and County policies, and to return all records, data,
equipment, and supplies immediately upon the request of Hennepin County. I understand that this Principal Place of Business
Designation Form must be renewed annually by February 1st.
Employee Signature: ________________________________________________________________ Date: ____________
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