Income Tax Refund Claim Form printable pdf download

Income Tax Refund Claim Form

INCOME TAX REFUND CLAIM

CITY OF SPRINGFIELD, INCOME TAX DIVISION

Employer

76 EAST HIGH STREET

Account #_______________

SPRINGFIELD, OHIO 45502

(FOR OFFICE USE ONLY)

PHONE (937) 324-7357

PLEASE REVIEW INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING FORM

PART A

Name

Phone #

( print first name, middle initial, last name )

Present Address

Email Address

( street, apt # )

Social Security #

( city, state and zip code )

Address During Period Covered by Claim, if different from present address:

From

( street, apt # )

( city and zip code )

TAX YEAR __________

REFUND AMOUNT CLAIMED $____________

PART B

Employer Name

Location Worked

Taxable

x 2%

Amount

= Refund

City Income

Tax Due

Withheld

Amount

Please provide a clear and concise explanation of reason for refund:

EMPLOYEE AFFIDAVIT: The undersigned states that all facts and figures given on this form are true and complete to

the best of his/her knowledge and belief; that no such refund has previously been claimed or received by him/her; and

understands that this information may be released to the Internal Revenue Service and the municipality of residence.

Employee Signature ____________________________ Title ______________________ Date _______________

PART C

EMPLOYER VERIFICATION AND AFFIDAVIT: I hereby certify that __________________(employee name) was

employed by the undersigned during the period for which said employee makes claim for refund and that the amount of

$___________________ was withheld in excess of his/her liability based on the above stated facts and calculations;

and that no portion of said tax withheld has been or will be refunded directly to the employee, and no adjustment in

withholding remittance has been or will be made. I further declare that the information contained herein is true and

correct to the best of my knowledge and belief and that I am authorized to provide this information.

Authorized Name _____________________________________ Title ______________________________________

( print first name, middle initial, last name)

Authorized Signature __________________________________ Date _____________________________________

Name of Employer ____________________________________ Phone ____________________________________

Income Tax Refund Claim Form

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