83-A272a - Wage Tax Refund Petition Salary/hourly Employees (Not To Be Used By Commissioned Employees)

ADVERTISEMENT

OFFICE USE ONLY
TAX YEAR
WAGE TAX REFUND PETITION
2016
SALARY/HOURLY EMPLOYEES
(Not to be used by Commissioned Employees)
Read the instructions for both the Employer as well as the Employee on the reverse side of this form prior to completing this petition.
Print or type all information. The completed petition must include:
W-2 showing Federal, State, Medicare and Local wages
Signature of Employee and Employer
IRS Form 2106 if claiming expenses on Line 2G. If Form 2106 has an entry on Line 4, submit a breakdown of those expenses.
EMPLOYEE'S NAME
SOCIAL SECURITY NUMBER
DAYTIME TELEPHONE NUMBER
HOME ADDRESS
OCCUPATION
CITY
STATE
ZIP CODE
IF PARTIAL YEAR, PROVIDE DATES:
From
To
EMPLOYER
EMPLOYER IDENTIFICATION NUMBER (EIN)
COLUMN A
COLUMN B
PLACE OF EMPLOYMENT
January 1, 2016 to June 30, 2016
July 1, 2016 to December 31, 2016
.00
.00
1. Gross Compensation per W-2
.00
.00
A. Non-Taxable Stock Options included in Line 1 (Must reflect on W-2)
.00
.00
B. Adjusted Gross Compensation (Subtract Line 1A from Line 1)
2. Computation of taxable compensation and/or allowable expenses
182 Days/1456 Hours
184 Days/1472 Hours
A. Number of Days/Hours (Include overtime from Line 2C)
B. Non-workdays/Hours (Total of weekend, vacation, holiday, sick or any type of leave time)
Days/Hours
Days/Hours
C. Number of actual Workdays/Hours (Base__________Overtime__________)
Days/Hours
Days/Hours
(Line 2A minus Line 2B) If computing overtime, see instructions on reverse.
D. Number of actual Days/Hours worked outside of Philadelphia in Line 2C. A list of dates and
locations when you worked outside of Philadelphia, verified and signed by your employer,
Days/Hours
Days/Hours
is required to be attached. Also provide a copy of Telework Agreement if applicable.
.
%
.
%
E. Percentage of time worked outside of Philadelphia.
Divide Line 2D by Line 2C.and round the resulting percentage to 4 decimal places.
.00
.00
F. Non-taxable compensation earned outside of Philadelphia (Line 1B times Line 2E)
G. (i) Total non-reimbursed business expenses from Form 2106 and/or
.00
.00
Schedule A, Miscellaneous Deductions
.00
.00
(ii) Multiply amount on Line G (i) by the percentage on Line 2E
.00
.00
(iii) Deductible non-reimbursed employee business expenses. Subtract Line G (ii) from Line G (i)
.00
.00
H. Non-taxable income and/or deductible employee business expenses Add Line 2F and Line 2G (iii)
.00
.00
3. Net Taxable compensation (Line 1B minus Line 2H)
Resident of Philadelphia multiply Line 3, Column A by .039102 and Column B by .039004.
4. TAX
.00
.00
Non-Resident of Philadelphia Line 3, Column A by .034828, and Column B by .034741.
DUE
.00
5. TOTAL TAX DUE (Add Line 4, Column A and Line 4, Column B.)
.00
6. Wage tax withheld per W-2
.00
7. REFUND REQUESTED (Line 6 minus Line 5)
EMPLOYER CERTIFICATION
I certify that the facts shown above supporting employee's claims are correct based on available payroll records. Individuals serving as authorized official
signatories should be familiar with employee's time and attendance, as well as applicable Wage Tax Regulations. Income Tax Regulations Section 401
through 404 requires that the employer withhold and allocate wages for tax purposes. General Regulation Section 306 (2) provides that the employer, for
and on behalf of the employee, requests the refund.
AUTHORIZED OFFICIAL SIGNATURE (Signature must be clear and legible.)
PRINTED NAME
DAYTIME TELEPHONE NUMBER
EMPLOYEE CERTIFICATION
I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my knowledge and
belief. I understand that if I knowingly make any false statements herein, I am subject to such penalties as may be prescribed by City Ordinance.
EMPLOYEE'S SIGNATURE (Signature must be clear and legible.)
DATE
83-A272A Rev. 1-3-2017

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2