Moving Assistance Authorization and Acknowledgement (A-33) Form
New Hire:
__________________________________________
Employment Start Date:
__________________________________________
Department:
__________________________________________
Hiring Authority (Dean/Director):
__________________________________________
Authorization
Payment of Moving Expenses (select one):
□ A lump sum payment for moving expenses in the total amount of $ __________________.
□ Reimbursement for allowable moving expenses up to the amount of $ _________________ through a
self-move.
□ Payment of allowable moving expenses up to the amount of $ _________________ through a
state/contracted move.
_____________________________________________________
Signature of Hiring Authority
__________________________
Date
New Hire Acknowledgement
I acknowledge that if I terminate or cause termination of my employment from Western Washington
University less than one year of my appointment effective date, I may be required to reimburse Western all
moving related costs reimbursed or lump sums received per the Paying Moving Expenses policy (POLU5348.15). I further authorize the University to withhold any sums due me as part of full repayment of such
costs in conformance with RCW 43.03. I understand that I am fully responsible for following IRS rules for filing
my annual 1040 tax form and that Western does not provide any tax advice.
If authorization is for a lump sum payment:
I further understand payment of the lump sum will not be paid to me until after my official employment start
date and will be reported as taxable income under a non-accountable plan.
If authorization is for reimbursement of moving expenses:
I further acknowledge receipt of a copy of the Employee Household Moving Guide or understand the Guide is
available on Western’s Relocation Services website at www.wwu.edu/bs/travel/relocations.shtml. I
understand that I must follow the Guide regarding the self-move requirements to qualify for reimbursement
FRM-U5348.15B Moving Assistance Authorization and Acknowledgement (A-33) Form
Moving Assistance Authorization and Acknowledgement (A-33) Form
and will be responsible for all costs that are not allowed, not authorized and/or in excess of the limit stated
above.
I understand that reimbursements will be made only in accordance the Reimbursing for Official University
Business policy (POL-U5348.12) after my official employment date and that all reimbursements will be
reported on my W-2 as reimbursed moving expenses under an accountable plan.
If authorization is for payment of a state/contracted move:
I further acknowledge receipt of a copy of the Employee Household Moving Guide or understand the Guide is
available on Western’s Relocation Services website at www.wwu.edu/bs/travel/relocations.shtml. I
understand that I must follow the Guide regarding the state/contracted move requirements to ensure
payment for allowable moving expenses and will be responsible for all costs that are not allowed, not
authorized and/or in excess of the limit stated above.
_____________________________________________________
Signature of New Hire
__________________________
Date
FRM-U5348.15B Moving Assistance Authorization and Acknowledgement (A-33) Form