Free AO 500 - Taxation for Commuting in Government-Provided Vehicle - Federal

OAO 500 (Rev. 9/02)

REPORTING PERIOD (FROM - TO):

TAXATION FOR COMMUTING IN GOVERNMENT - PROVIDED VEHICLE
NAME: OFFICE LOCATION:
MONTH/ DAY TAX BENEFIT MONTH/ DAY TAX BENEFIT MONTH/ DAY TAX BENEFIT MONTH/ DAY TAX BENEFIT MONTH/ DAY TAX BENEFIT

TITLE:

DISTRICT:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.

61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80.

81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100.

SUBTOTAL

0.00

SUBTOTAL

0.00

SUBTOTAL

0.00

SUBTOTAL TOTAL

0.00

SUBTOTAL

0.00

<
DATE

$0.00

I HEREBY CERTIFY THAT THE ABOVE IS TRUE AND CORRECT.
EMPLOYEE SIGNATURE DATE CERTIFYING OFFICER

AO 500 REVERSE (Rev. 9/02)

TAXATION FOR COMMUTING IN GOVERNMENT - PROVIDED VEHICLE
NAME: DISTRICT: TITLE: OFFICE LOCATION: SOCIAL SECURITY:

ADMINISTRATIVE OFFICE OF THE UNITED STATES COURTS HUMAN RESOURCES DIVISION COURT SERVICES BRANCH WASHINGTON, D.C. 20544

= FORM MUST BE

SUBMITTED IN A WINDOW ENVELOPE TO:

This report covers the total taxable benefit for the usage of a government vehicle for period of time from: November 1, to October 31, . To determine the total amount of Taxable Benefit, multiply the number of commutes by the current value of the commute. (Please refer to the memorandum entitled "Taxation for Commuting in Government Provided Vehicle.") TOTAL AMOUNT OF TAXABLE BENEFIT:
$0.00

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