First Name:  Middle Initial:  Last Name:
             
                        Current Employee         New Employee

This declaration details parsonage allowance to comply with section 107 of the Internal Revenue Code. 
The housing or parsonage allowance is an "exclusion" and is not reported as income. 

The Parsonage Allowance is exempt from Federal & State Tax withholding, but not Social Security and Medicare 
(FICA) tax withholding. The University reserves the right to determine the reasonableness of the amount declared. 

Housing options:            Own    Rental Housing       University Rental Housing

Housing/Parsonage allowance amount (monthly):

Please note: The University reserves the right to determine the reasonableness of the 
amount declared. If your housing option changes and your monthly expenses are 
significantly affected, please complete a this form to declare a new allowance.

Estimated Monthly expenses:

Rent or Mortgage amount            
Real Estate Taxes                        
Insurance on home and contents   
Utilities
Maintenance
Other (detail)

I understand that under section 107 of the Internal Revenue Code, the burden of proof, 
with regard to the above amount being allowed for housing/parsonage, is solely my  responsibility. 
Wesleyan shall incur no liability whatsoever with regard to taxes related to this allowance.

 Signature:                                           Title:                                                                                    Date:
   

 University Approval:                          Department:                                                                        Date:
       

Please sign and submit this form by January 10th. A signed, approved copy will
be mailed to you for your records.