Code of Federal Regulations Title 41. Public Contracts and Property Management § 41.302–17.63 What information should I provide to my agency to make the RITA calculation possible under the 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