2024 Model Form – Wisconsin Legislators 
                  (For Making Internal Revenue Code Section 162(h) Election) 

Name                                                                        
Address                                                                      Residence within 
                                                                             Legislative District 
                                                                            
Social Security Number                                                      

For the tax year 2024 I have elected my district home as my tax home and I am now applying section 162(h) of the Internal 
Revenue Code which allows a per diem expense for living expenses attributable to my work as a state legislator for every 
legislative day. 

The number of miles between my residence within my legislative district and the capitol building is                                             .  

The number of my legislative days for tax year 2024 includes: 
                  Session days (including recesses of four consecutive days or less) 
                  Committee meeting days 
                  Total legislative days 

The per diem rate I am using is the federal employee per diem rate that was in effect for Madison for 2024. This rate was 
$173 for the period January 1 through March 31, $195 for the period April 1 through September 30, $218 for the period 
October 1 through October 31, and $190 for the period November 1 through December 31.  

1.  Enter reimbursements received from your employer that weren’t reported to you in box 1 of Form 
 W-2. Include any reimbursements reported under code “L” in box 12 of your Form W-2 ................... 1.                                          

 Note: The per diem amounts below are in calendar order. 

2a.        Legislative days at $173 per day ......................... 2a.    

2b.        Legislative days at $195 per day ......................... 2b.    

2c.        Legislative days at $190 per day ......................... 2c.    

2d.        Legislative days at $218 per day ......................... 2d.    

2e. Total per diem expenses. Add lines 2a through 2d ........................................... 2e. _____________  

3.  Expenses not reported on line 2e (See instructions on page 3) ....................... 3.   _____________  

4.  Total expenses. Add lines 2e and 3 .................................................................................................... 4.      

5.  Subtract line 4 from line 1. If zero or less, enter -0- (no deduction is allowed). However, if line 1  
 is greater than line 4, report the excess as income on federal Forms 1040, 1040-SR, or 1040NR.  
 See the instructions for these forms for the lines on which to report these amounts .......................... 5.                                  

Note: Do not include on lines 2a through 2d any legislative day for which you are claiming actual expenses on line 3. 

SPL-01 (R. 12-24)                                                                                          Wisconsin  Department  of  Revenue