To
Receipt Stamp
________________________
________________________
________________________
Request for Reimbursement
of Relocation Expenses
Please check or fill in clearly
Applicant (section 1 subsection 1 Act on Relocation Expenses of the Land Baden-Württemberg
(LUKG))
Last name, first name
Position/title
Employer
Personnel number
Phone (workplace)
Confirmation of Reimbursement (section 2 subsection 1, sections 3 and 4 LUKG)
Date of reimbursement confirmation (please enclose a copy)
Date of announcement
Reason for relocation (e.g. secondment, transfer)
Kostenstelle / PSP
Fonds
__ __ __ __ __ __ __ __ __ __
__ __ __ __
Personal Data
On the day before loading the goods
I (was)
Remuneration bracket on the day before loading the goods
 not married
 married
 had the status of a married person (see note 1)
Relocation Details
Address of former workplace (ZIP code, city, street name, house no.)
Address of new workplace (ZIP code, city, street name, house no.)
Address of former residence (ZIP code, city, street name, house no.)
Address of new residence (ZIP code, city, street name, house no.)
Loading of goods (date)
Unloading of goods (date)
On the day before loading the goods I had
After the relocation I had
 a residence
 a residence
 no residence
 no residence
within the meaning of section 10 subsection 4 LUKG (see note 2)
within the meaning of section 10 subsection 4 LUKG (see note 2)
The following persons moved with me and are living with me in a common household:
 spouse
 unmarried children, stepchildren and foster children
First name, last name
 persons according to section 6 subsection 3 sentence 3
LUKG (see note 3)
First name, last name, family relationship
Last Relocation (section 10 subsection 6 LUKG)
In the last five years before the above mentioned relocation
 no relocation with reimbursement of expenses took place.
 a relocation with reimbursement of expenses according to sections 3, 4 subsection 1(2–6) LUKG took place (please enclose a
copy of the reimbursement confirmation).
Completion of last relocation
The reimbursement was made by
Date
Employer
I lived in a residence within the meaning of section 10
 yes
subsection 4 LUKG before and after the last relocation:
 no
Request for Reimbursement of Relocation Expenses
I hereby apply for the reimbursement of the following relocation expenses and the fixed amount for other relocation costs.
Please transfer the amount to the following bank account:
Bank Code/BIC
Bank
Account Number/IBAN
Did another person, with whom the relocation was completed, receive a reimbursement for this relocation?
 no
 yes (please enclose a copy of the reimbursement confirmation)
For the requested reimbursement, I, or one of the persons who moved with me and lives with me in a common household
received
 a grant
Amount in EUR
Employer
 an advance
Amount in EUR
Employer
Declaration
I hereby confirm that the information provided above is accurate and complete. The relocation expenses were actually incurred.
I requested the enclosed quotes from the moving companies myself. I am aware that I have to repay the reimbursement
according to section 4 subsection 1(1) LUKG (relocation due to hiring) if I self-determinedly discontinue my job within two years
of the relocation (section 5 subsection 3 LUKG).
City, Date
Signature
Notes:
1)
Equal to married persons are widowed persons, divorced persons, persons, whose marriage was annulled, unmarried
persons who, for legal or moral reasons, permanently took in relatives up to the fourth degree, relatives by marriage up to
the second degree, foster children or foster parents, and unmarried persons who permanently took in a person whose
permanent assistance they require for professional or health reasons.
2)
A residence within the meaning of section 10 subsection 4 LUKG consists of a self-contained unit of several rooms in
which the household can be kept, always including a kitchen or a room with a cooking facility. A residence furthermore
includes water supply, water disposal and a toilet. Unmarried persons entitled to reimbursement of relocation expenses
only have a residence if they alone or together with other persons have the right of disposition of the residence. The
adherence to these conditions is to be proved adequately (e.g. rental agreement).
3)
The persons listed in section 6 subsection 3 sentence 3 LUKG do include married children, relatives up to the fourth
degree, relatives by marriage up to the second degree and foster parents if the person entitled to reimbursement of
relocation expenses took them in permanently for legal or moral reasons. Also included are household staff and other
persons, whose permanent assistance the person entitled to reimbursement of relocation expenses requires for
professional or health reasons. The personal and financial situation of these persons has to be stated on a separate page.
Calculation of Relocation Expenses
Receipt
no.
Type of Expense
Calculation of Costs
- to be filled in by the Human Resources division -
EUR
1.
Transportation expenses (section 6 LUKG)
1.1
Relocation without moving company
EUR
Explanatory Notes
Substantiated necessary expenses
1.2
Relocation with moving company
At least 3 quotes giving a fixed price are attached.
Receipts of the moving company with the lowest price. The
services agreed in the contract with the moving company
have been performed completely.
2.
Travel expenses (section 7 LUKG)
2.1
Relocation travel
___ days x ____ euros x __
persons
from (date, time)
until (date, time)
__ nights x ____ euros x __
persons
Substantiated expenses for meals and lodging:
 public transportation costs (enclose receipts)
 personal vehicle
kilometers traveled
no. of passengers
______ km x cents x ______
cents
Valid reason for use of personal vehicle
 no
______ km x ______ cents
 yes, because ______________________________
_________________________________________________
2.2
Travel for showings
from
to
1. trip
_____ days x _____ persons
2. trip
_____ days x _____ persons
from (date, time)
until (date, time)
1. trip
_____ nights x _____ persons
2. trip
_____ nights x _____ persons
Substantiated expenses for meals and lodging:
 public transportation costs (enclose receipts)
 personal vehicle
kilometers traveled
1. trip
______ km x ______ cents
2. trip
______ km x ______ cents
Valid reason for use of personal vehicle
 no
 yes, because ______________________________
_________________________________________________
2.3
Travel for preparation (to former apartment)
 public transportation costs (enclose receipts)
 personal vehicle
kilometers traveled
______ km x ______ cents
Valid reason for use of personal vehicle
 no
 yes, because _____________________________
_________________________________________________
sub-total / amount carried forward
Receipt
no.
Type of Expense
Calculation of Costs
- to be filled in by the Human Resources division -
EUR
3.
Rent compensation (section 8 LUKG)
EUR
Explanatory Notes:
Amount carried forward
For a transition period, rent had to be paid for two residences.
The corresponding documents are enclosed (e.g. rental
agreements, receipts, rental agreement termination letter)
3.1
Former residence (garage)
Rental agreement canceled
End of rental agreement
on (date)
(date)
rent after the
relocation
For 6 months at the longest
The residence (garage) has been rented out to or used by
others partly or completely for that period of time:
 no
 yes
from
until
Expenses for early subletting
3.2
One month's rent at the most
New residence (garage)
Rented from (date)
rent before
the relocation
Moved in (date)
For 3 months at the longest
The residence (garage) has been rented out to or used by
others partly or completely for that period of time:
 no
4.
 yes
from
until
Realtor's commission (section 9 LUKG)
Please enclose the receipt of the realtor's commission. It has
to be an amount customary for the place of residence.
5.
Expenses for relocation preparations
(section 11 LUKG)
Substantiated relocation expenses in the event of a
revocation of the confirmation of reimbursement.
I have enclosed the document of the revocation of the
confirmation of reimbursement.
Calculation of costs - to be filled in by the Human
Resources division
6.
Fixed amount (section 10 LUKG)
Maximal amount:
2 months' rent plus VAT
Maximal amount for other
relocation costs: fixed repayment
according to section 10 LUKG
Total
Increased amount
Tariff class _____________
_______ euros x ______ per cent
of amount
_______ euros x _______
persons
Frequency premium
50 per cent of the basic amount
Basic amount
Reimbursement of relocation expenses
7.
Grant (section 5 subsection 2 LUKG)
8.
Advance
 to disburse
Confirmation of factual accuracy sachlich und rechnerisch richtig:
 to collect
_____________________________________________
(Date, Signature)