0515 Form 9214 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f9214.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(May 2015)

Department of the Treasury - Internal Revenue Service

Taxpayer's name and address In reply refer to:

Tax year

Last four digits of Social Security Number

Principal place of employment

To assist us in the examination of your return, provide the following requested information and documentation. If more than one move was made this year, please complete a separate Questionnaire for each move.

Date of move Tax year of move

To where you moved From where you moved

Are expenses for this move being claimed in more than one tax year Yes No

If Yes, furnish a copy of your tax return for the other year.

Was your move between foreign countries Yes No

If Yes, provide a schedule showing the income earned in each country for the year of the move.

Show the period of time you were employed at the new location From To

Were you reimbursed by your employer for moving expenses Yes No

Did your employer provide you with a Form 4782, Employee Moving Expense Information, (or equivalent statement) which shows the moving expenses paid directly to you on your behalf to a third party (such as airlines, movers, hotels, etc.)

If Yes, furnish a copy.

Name and address of employer

Yes No

Were amounts reimbursed for your moving expenses shown on your Form W-2 Yes No

If Yes, provide a reconciliation between W-2 amounts and amounts shown on your return. Provide an explanation for any differences.

Note: Provide copies of receipts for all expenses claimed on your Form 3903, Moving Expenses . If original documents are submitted, they will be returned to you at the conclusion of the examination.

Even if you have not shown a deduction for moving expenses on your return (Form 3903 attach to your return) furnish the above requested information and documentation.

Certification: Under penalties of perjury, I declare that I have examined this statement and, to the best of my knowledge and belief, it is true, correct, and complete.