Refund Request Form Page 2
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1
2REFUND REQUEST FORM
Tax Year __________________
City/Village _______________________
DEPARTMENT OF TAXATION
A SEPARATE FORM
106 E. SPRING STREET
MUST BE FILED FOR
ST. MARYS, OHIO 45885
EACH EMPLOYER AND
419-394-3303, ext. 107
FOR EACH YEAR.
PART A: (To be completed by Taxpayer)
NAME OF APPLICANT_____________________________
SOCIAL SECURITY NO.___________________
CURRENT ADDRESS_________________________________________________________________________
STREET ADDRESS DURING CLAIM PERIOD____________________________________________________
Beginning and ending dates of residency at above address:
From:__________________
To:_____________________
:______________
NAME OF CITY OF WHERE YOU ACTUALLY PERFORMED SERVICES FOR YOUR EMPLOYER
EMPLOYER'S NAME____________________
EMPLOYER'S MAILING ADDRESS_____________________
COMPUTATION OF AMOUNT CLAIMED:
A)
Total gross wages as reported on W-2 (W-2 must be attached)
$
B)
Subtract nontaxable wages (From Line B computation above)
( $
)
C)
Total taxable income (Line A minus Line B)
$
D)
Tax due, Line C multiplied by _____% (See tax rates above)
$
E)
Subtract tax withheld as shown on attached W-2
( $
)
F)
Amount of refund claimed
$
EXPLANATION OF REFUND:__________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
I AUTHORIZE THE DEPARTMENT OF TAXATION TO FURNISH THE TAX DEPARTMENT FOR MY CITY OF
RESIDENCE OR EMPLOYMENT, A COPY OF THIS REFUND REQUEST. THE UNDERSIGNED DECLARES THAT ALL
INFORMATION GIVEN IS TRUE AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT A
REFUND HAS NOT BEEN CLAIMED OR RECEIVED BY HIM/HER FOR THE PERIOD COVERED BY THIS CLAIM.
Signed_________________________________
D
ate______________________
PART B: CERTIFICATION OF EMPLOYER: (Must be completed by employer only)
I verify that during the tax year ______, my company withheld $____________ City tax in excess of his/her liability. The statements
made above and any log attached has been reviewed by myself and found to be in keeping with my company's records. I also verify
that no portion of said tax has been or will be refunded directly to the employee from my company and that no adjustments have been
or will be made to my company's city tax withholding account for said tax.
Signed____________________________
Title______________________________
Date____________________
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