You should provide the information required in the “Statement of Income and Tax Filing Status” shown below. This information should be taken from the income tax returns you filed for Year 1.
Statement of Income and Tax Filing Status - Two-Year Process
| The following information, which my agency will use in calculating the RITA to which I am entitled, was shown on the Federal, state and local income tax returns that I (or my spouse and I) filed for the 20____ tax year. | |
| Federal Filing status: | |
| ☐ Single | ☐ Head of Household |
| ☐ Married Filing Jointly | ☐ Qualifying Widow(er) |
| ☐ Married Filing Separately | |
| Taxable income as shown on my (our) IRS Form 1040: $____ | |
| State you are moving out of: ________ | |
| Filing status for the state moving out of: ______ | |
| Marginal Tax Rate: ___% | |
| State you are moving into: ________ | |
| Filing status for the state moving into: ________ | |
| Marginal Tax Rate: ____% | |
| Locality you are moving out of: ________ | |
| Filing status for the locality moving out of: ________ | |
| Marginal Tax Rate: ____% | |
| Locality you are moving into: ________ | |
| Filing status for the locality moving into: ________ | |
| Marginal Tax Rate: ____% | |
| The above information is true and accurate to the best of my (our) knowledge. I (we) agree to notify the appropriate agency official of any significant changes to the above so that appropriate adjustments to the RITA can be made. | |
| __________________ | __________ |
| Employee's signature | Date |
| __________________ | __________ |
| Spouse's signature (if filing jointly) | Date |