REQUEST FOR REIMBURSEMENT OF RELOCATION EXPENSES
EMPLOYEE INFORMATION
Employee Name
Title
Hiring Department
Hire Date
IRS DISTANCE TEST
Employee's Previous
Residence
New Residence (if
known)
Distance from Previous
Residence to Previous
Employer
Distance from Previous
Residence to new
Employer (AU)
RELOCATION EXPENSE AUTHORIZATION
Maximum Reimbursement Authorized (per the REA)
Cumulative Amount of Prior Reimbursement Requests, if applicable
Remaining Maximum Reimbursable
Is This The Final Reimbursement Request?
Funding CFC
(per the REA)
Fund
-
Department
-
Program
-
Class
-
Project
CERTIFICATION AND APPROVAL
I certify that the expenses listed below were incurred by me for the purpose of personal relocation in connection with my employment with the
Augusta University and in accordance with the terms agreed upon in the Relocation and Moving Expense Agreement
Employee Signature and Date
I have reviewed the expenses shown on this reimbursement request and find them to be reasonable and appropriate and in conformity with both
the Relocation and Moving Expense Agreement and with AU's Relocation & Moving Expense Policy
Department Head Signature and Date
Check box for payment to a third party.
A separate request should be submitted for items reimbursable directly to the employee.
*Attach a copy of the Relocation Expense Authorization Form and Relocation and
Moving Expense Agreement. Mail to the Payroll Office, HSB-122
REQUEST FOR REIMBURSEMENT OF RELOCATION EXPENSES
(page 2)
QUALIFIED EXPENSES (Non-Taxable)
TRANSPORTATION OF HOUSEHOLD GOODS
Common Carrier $
Moving Truck Rental (for self-moves) $
Moving Truck Fuel (for self-moves) $
Insurance on Personal Possessions in Transit $
Labor to Pack and Move Personal Possessions (up to a maximum
of $500) $
Packing Supplies $
Temporary Storage (30 days or less) $
Subtotal - Transportation of Goods
0.00
TRAVEL TO NEW RESIDENCE (Final Move)
(If this is a Househunting/ Preliminary Trip, Complete the NonQualified Section Below)
Air or Train Fare: No. Passengers (Spouse & Dependents only)
____ x Airfare per Person $______ $
Rental Car
$
Rental Car Fuel
$
Travel by Personal Vehicle: Miles _____ x Rate ______
$
Tolls, Parking, Shuttle Service
$
Lodging: No. of Nights ___ x Average Rate / Night $_______
$
0.00
0.00
Subtotal - Travel
0.00
TOTAL QUALIFIED EXPENSES (acct 565100)
0.00
NONQUALIFIED EXPENSES (Taxable)
PRE-MOVE TRAVEL
Describe Purpose of Trip: _______________________________________________________
Air or Train Fare: No. Passengers (Spouse & Dependents only)
____ x Airfare per Person $______
$
Rental Car
$
Rental Car Fuel
$
Travel by Personal Vehicle: Miles _____ x Rate $_____
$
Tolls, Parking, Shuttle Service
$
Lodging: No. of Nights ___ x Average Rate / Night $_______
$
Subtotal - Travel
0.00
0.00
0.00
Temporary Storage (31 days to 6 months)
$
Temporary Living Quarters (up to 6 months)
$
MEALS:
Breakfast: Qty ____ x Per Diem $____
$
0.00
MEALS:
Lunch: Qty ____ x Per Diem $____
$
0.00
MEALS:
Dinner: Qty ____ x Per Diem $____
$
0.00
Subtotal - Meals & Misc
TOTAL NONQUALIFIED EXPENSES (acct 565101)
0.00
TOTAL OF THIS CLAIM
0.00
0.00
Revised 05/17
Accounts Payable Relocation and Moving Expense Agreement
Agreement made on ___________________, between Augusta University (AU)
and_________________________________________________ (Employee),
Witness:
Whereas Employee, with employment date effective_____________, is a suitable candidate for the
position(s) of _________________________and has accepted AU’s offer of employment into this
position effective__________________; and
Whereas AU and Employee mutually desire to move and relocate Employee’s residence from
____________________________________________________,
to________________________________________________ so that Employee’s residence is in the
area of Employee’s employment; now, therefore, AU and Employee agree;
1. Effective __________________________, Employee agrees to work on full-time basis at AU
for at least one year beginning __________________________and
ending__________________________________. For faculty appointed on an academic year
basis, one year is defined as two concurrent regular academic sessions of fall and spring or
spring and fall semesters equal to nine months. For all other faculty and employees, one year is
defined as twelve months.
2. AU agrees to reimburse or pay on the behalf of Employee an amount not to exceed
$_____________________for personal moving and relocation expenses incurred for
relocation. This amount includes payments made on behalf of Employee by AU to thirdparty companies and providers. Employee agrees to provide original receipts for all
reimbursement claims. In accordance with IRS guidelines, receipts must be submitted within
sixty (60) days of completion of the move to be considered as qualified, nontaxable moving
expenses. Expenses submitted for reimbursement after sixty (60) days will be considered
taxable income. Employee agrees that only those personal moving and relocation expenses
incurred after the date of execution of this agreement can be submitted for payment or
reimbursement.
3. Applicable federal and state laws require “nonqualified, taxable” reimbursements to
relocate employees to be included in the employee’s gross income and “qualified, non-taxable”
relocation expenses to be excluded. Based on the passage of the 1993 Revenue Reconciliation
Act, qualified, non-taxable moving expenses are defined as the reasonable costs of 1) moving
household goods and personal effects from the former residence to the new residence (including
common carrier and storage for up to thirty days), and 2) Traveling (including lodging during
the period of travel) from the former residence to the new residence. Qualified moving expenses
DO NOT include any expenses for meals. All other reimbursements are considered nonqualified
and are taxable to the employee. Any amounts which are considered nonqualified will be
reimbursed net of tax withholdings and will be reported as income to the Internal Revenue
Service.
4. Employee’s failure to remain employed at AU for the applicable period in Section 1 will
constitute a violation of the agreement. In the event of such violation, Employee will beliable
to AU for all or a pro-rated portion of the gross (pre-tax) relocation and moving expenses
which AU has paid to or on behalf of Employee. Any tax impact, if applicable to the
original payment or reimbursement, will be reversed upon receipt of repayment from the
employee.
5. Employee hereby gives AU an express lien on all salaries, wages, and other sums payable to
him/her by AU, for the purpose of securing all amounts due under Section 4 above, and
Employee authorizes AU to withhold all amounts so due from the sum payable to Employee by
AU. Employee waives all exemptions, which may apply to any amounts so due. Employee
agrees to pay to AU upon request any amount which is not so deducted. In the event Employee
fails to pay all amounts due AU within thirty (30) days of AU’s request, Employee
acknowledges and agrees that AU may undertake collection efforts including but not limited to
referral to a collection agency. Employee agrees to pay all the collection costs, including
attorney fees and other charges necessary for the collection of any amount still due AU
hereunder.
6. If Employee fails to remain employed as indicated in Section 1 above for reasons beyond his/
her control considered sufficient by AU, all or part of the liability under Section 4 may be
waived by AU. Any such waiver must be approved in writing by the hiring department, the
appropriate Dean or Vice President, and the Vice President. The hiring department, Dean or
Vice President whose account(s) paid for Employee’s move must promptly notify the Payroll
Department if Employee does not remain at AU for at least one year.
7. AU will not reimburse employees, nor make payments to third party movers on employees’
behalf, for moving expenses and relocation expenses already reimbursed or to be reimbursed by
another entity.
8. AU shall have no responsibility or legal liability for goods damaged as a result of the
relocation. Employee must make any claim for damage to household good in transit directly to
the moving company.
__________________ ________
Employee (Signature /Date)
_____________________________
Department Head (Signature/Date)
_________________________
Employee (Print or Type )
___________________________
Department Head (Print or Type)
_________________________
Hire Date
___________________________
Department Name and Number
_________________________
Department Contact (Name, phone ext)
__________________________
Senior Vice President (Signature, Date)
(Vice President for Finance signature required for reimbursements of $15,000 or more)
Revised 04/16