Revised: October 18, 2013
Southern Illinois University Edwardsville
Employee Moving Expense Certification
(For more information concerning employee moving expenses, see IRS Publication 521, Moving Expenses)
Purpose:
This form is to be completed by the hiring department to request an employee moving expense
reimbursement and/or report employee moving expenses paid directly by/provided by the University
and/or the SIUE Foundation for tax reporting determination purposes. If employee is requesting a
reimbursement, this form must be accompanied by original receipts/invoices and must be submitted to
Purchasing within 60 days of when the moving expenses were paid or have been incurred. Otherwise, the
University may treat the otherwise nontaxable moving expenses as taxable wages.
General Tax Treatment:
Whether employer-paid moving expenses are wages to the employee depends on whether:



the employer’s reimbursement arrangement is an accountable or nonaccountable plan;
the employee meets the three specific tests established by the IRS:
1. Move Related to Start of Work
2. Distance Test
3. Time Test; and
the moving expense is qualified or nonqualified as defined by the IRS.
PART I: EMPLOYEE INFORMATION
EMPLOYEE NAME: ___________________________________________________________ BANNER ID: 800 - ___ ___ - ___ ___ ___ ___
Last
First
M.I.
IS THE PAYMENT MADE TO OR ON THE BEHALF OF A U.S. CITIZEN OR PERMANENT RESIDENT? YES □ NO □
HIRING DEPARTMENT: _______________________________________________ ACCOUNT NUMBER: _________________________
HIRING DEPARTMENT CONTACT NAME: __________________________________ EMAIL: _____________ PHONE: ___________
PART II: DISTANCE TEST AND TIME TEST
OLD HOME:
NEW HOME:
_________________________________________________________
Address
_________________________________________________________
City
State
Zip Code
_______________________________________________________
Address
________________________________________________________
City
State
Zip Code
1. Number of miles from old home to the University: _____________
2. Number of miles from old home to old workplace*: _____________
3. Subtract Line 2 from Line 1 (if zero or less, enter -0-): __________
Is Line 3 at least 50 miles?
□ YES
Go to question 4
□ NO
All University-paid moving expenses are taxable wages and reported on Form W-2. Continue with form.
4. Does the University expect to employ this individual for 39 out of the next 52 weeks?
□ YES
Continue with form.
□ NO
All University-paid moving expenses are taxable wages and reported on Form W-2. Continue with form.
* In the case of an employee taking a first full-time position or coming back to work from long-term part-time work or unemployment, the distance test is
met if the University is at least 50 miles from the old home.
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PART III: SUPPLEMENTAL INFORMATION
MOVING EXPENSE BUDGET CAP ALLOWED $ _______________________
COMPANY CONTRACTED FOR MOVE (IF PAID DIRECTLY BY UNIVERSITY AND/OR SIUE FOUNDATION):
_______________________________________________________________________________________________ __ __ - __ __ __ __ __ __ __
Company Name
FEIN
________________________________________________________________________________________________________________________
Address
____________________________________________________________________________________________________________________________________________________________________________________
City
State
Zip Code
SCHEDULED DATE OF ARRIVAL: ______________________________________________________________________________________
EMPLOYEE DESIRES TO: (please check one only)
□ Pay company in full and be reimbursed for the University’s share of costs.
□ Pay his/her share, and have the University pay its share directly to the moving company named above.
PART IV: MOVING EXPENSES
IRS DEFINED
QUALIFIED EXPENSES
Moving Van Line
Rental Truck or Trailer
Storage Costs (Up to 30 Days)
Airfare (Final Trip For Employee and
Each Member of Household)
Lodging (Not Meals)
Auto Expenses (Final Trip For Employee
and Each Member of Household): Actual
Gas and Oil Cost or Miles at IRS Deemed
Rate***
Parking Fees and Tolls
Packing and Crating Supplies
Other (Attach Detail)
SUBTOTAL
EMPLOYEE
REIMBURSEMENT
(Non-Taxable, Form
W-2, Box 12, Code P)
UNIVERSITY AND/OR SIUE FOUNDATION
PAID TO
THIRD PARTY
SERVICES PROVIDED
(Not Reportable on
IN KIND **
Form W-2)
(Not Reportable on Form W-2)
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
$
UNIVERSITY AND/OR SIUE FOUNDATION
IRS DEFINED
NONQUALIFIED EXPENSES
Meals Incurred on Final Trip
Pre-Move Househunting Trips
(Examples: Travel, Meals, and Lodging)
Temporary Living Expenses
Other (Attach Detail)
SUBTOTAL
TOTAL
EMPLOYEE
REIMBURSEMENT
(Taxable Wages, Form
W-2, Subject to Tax
Withholding
at Time of Payment)
PAID TO
THIRD PARTY
(Taxable Wages,
Form W-2, Subject
to Tax Withholding)
SERVICES PROVIDED
IN KIND **
(Taxable Wages, Form W-2,
Subject to Tax Withholding)
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
Note: The rules above only apply to moves within the United States or moves from a foreign country to the United States.
** For example, the value of University-provided temporary housing.
*** For current IRS deemed rate, please contact Sharon Giffhorn at 618-650-3384 or sgiffho@siue.edu.
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PART V: EMPLOYEE ACKNOWLEDGMENT
I understand that if I do not meet the IRS tests in Part II and/or I do not supply adequate documentation to my hiring department within
60 days of when the moving expenses were paid or incurred, all moving expenses will be treated as wages and reported on my Form W-2.
I understand that if I meet the IRS tests in Part II and supply adequate documentation to my hiring department within 60 days of when the
moving expenses were paid or incurred, only nonqualified moving expenses are treated as wages, subject to applicable tax withholding, and
reported on my Form W-2.
EMPLOYEE SIGNATURE: ___________________________________________________________ DATE: _______________
PART VI: AUTHORIZATION
DEPARTMENT DEAN OR DIRECTOR SIGNATURE: ___________________________________ DATE: ______________
VICE CHANCELLOR SIGNATURE: ____________________________________________________ DATE: ______________
PART VII: PURCHASING DEPARTMENT REVIEW OF PART IV
APROVED PART IV AS IS □ CORRECTION(S) TO PART IV MADE □
If a change(s) is made to Part IV, a copy of this form with the change will be sent to the contact person of the hiring department and a
copy to the employee. A copy of this form will be forwarded to Payroll for proper tax reporting and treatment and, if applicable, to
Accounts Payable for payment processing.
PURCHASING DEPARTMENT REVIEWER’S SIGNATURE: _____________________________
DATE: ______________
For moving expense questions please contact Sharon Giffhorn at 618-650-3384 or sgiffho@siue.edu.
This form is maintained by the Office of Tax Compliance. For questions, comments, concerns, or suggestions about this form please
contact the Office of Tax Compliance.
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