Form 07-1466 - Employee Application For Refund - 2011

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EMPLOYEE APPLICATION FOR REFUND
Alaska Department of Labor
Telephone: 907-465-2757
and Workforce Development
For Calendar Year ______________
Toll Free: 1-888-448-3527
Employment Security Tax
TDD/TTY 1-800-770-8973
Applicant mailing address: The address you provide will update all your unemployment
P.O. Box 115509
Fax: 907-465-2374
insurance mailing addresses. This includes the address for mailing your unemployment
Juneau, AK 99811-5509
insurance benefit information and/or payments and your employee refund.
Please read instruction page before completing
You are eligible for a refund of excess employee contributions to the Unemployment Insurance Trust Fund if:
you were employed by two or more liable employers who contributed to the Alaska UI Trust Fund during a calendar year,
you had withholdings from your wages that exceed the maximum annual employee tax,
this application is filed by December 31 of the year following the year in which the deductions were made,
you provide copies of your Statement of Deductions (W-2’s) from each employer you worked for during the year, and
your overpayment is $5.00 or greater.
Name: ____________________________________________________ Social Security Number:
__________________________
Mailing Address: ____________________________________________ Daytime Telephone:
____________________________
City: ______________________________________________________ State: __________ Zip: ___________________________
Do Not Use
Employee
Do Not Use
Name of Your Employers
Shaded
Gross Wages
Contributions
Shaded
(Please type or print clearly.)
Spaces
Received
Deducted
Spaces
$
$
$
$
I certify that the above information is true and
TOTALS
correct to the best of my knowledge and belief.
$ (
)
Less Maximum Employee
Contribution
$
Applicant's Signature: _________________________________________________
REFUND
Date: _________________________________________________
Form 07-1466 (03/11)

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