Claim For Refund Form - City Of Louisville, Ohio
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1
2CLAIM FOR REFUND
FOR TAX OFFICE USE:
This form must cover one calendar year and one employer only.
Approved By:
FORM W-2 MUST BE ATTACHED.
TAX YEAR TC:______
TA:______
Name of Applicant _________________________________________________________________
Refund Amt:
Last
First
Middle
$
Present Address ___________________________________________________________________
POST:________________
Address
Date:________________
City
State
Zip
Social Security # ______________________________
City of Employment ____________________________________
Withholding Account # __________________________________
(Employers Only)
The undersigned hereby makes claim for refund of Louisville City Income Tax
In the amount of $____________________
While in the employ of
(address where work was performed) _________________________________________________________________________
For the period:
To:________________________ From:_______________________________
Resident Address for this period_____________________________________________________________________________
Address
City/State
Zip
Reason (
) _______________________________________
explain fully. In addition, attach schedule of dates and locations worked out
AND FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER. TAX PAYER ALSO UNDERSTANDS THIS
INFORMATION MAY BE RELEASED TO TAX ADMINISTRATION OF THE CITY OF RESIDENCE AND THE I.R.S.
Signed_______________________________________
Date______________________
Phone_______________________
Claimant's signature
CERTIFICATION OF EMPLOYER
I/We hereby certify that the above employee was employed by the undersigned during the period for which said employee
makes claim for refund and that the total amount of $____________ was withheld for the year _______; the said employee
was not, during the period claimed above, working inside corporate limits of the City; that no portion of said tax withheld has
been or will be refunded to said employee; and that no adjustment has been or will be made in remitting taxes withheld to
the city.
____________________________________________________
By:___________________________________________
Name of Employer
Signature of Officer
Date _____________ FID ________________________ Title ______________________ Phone _______________________
NOTICE:
*This refund may result in an amendment to Federal, State, or other City tax returns
*Refund of $10.00 or more are reported to I.R.S.
*Please allow 90 days for processing of your refund request
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