Cca Form 120-18 - Application For Refund 2006
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1
2APPLICATION FOR REFUND
PHONE: (216) 664-2070
OHIO TOLL FREE
(year)
CCA - MUNICIPAL INCOME TAX
1-800-223-6317
205 W Saint Clair Ave
MAIL TO:
CLEVELAND, OHIO 44113-1503
CCA FORM 120-18 rev. 12/06
Check Status: ❑ ❑ ❑ ❑ ❑ Individual
❑ ❑ ❑ ❑ ❑ Joint
Your social security number
Spouse’s social security number
-
IF MOVED DURING YEAR
Your first name and initial
Last name
Enter date moved:
/
/
.
MONTH
DAY
YEAR
If a joint return, spouse’s first name and initial
Last name
Enter former address:
Home address (number and street)
Apt. No.
Home address (number and street)
Apt. No.
City, town or post office, state, and ZIP code
City, town or post office, state, and ZIP code
INDICATE IN BLOCK BELOW THE KIND OF CLAIM FILED (SEE INSTRUCTIONS)
❑ ❑ ❑ ❑ ❑
Refund of municipal income tax withheld for all or part of year that Applicant was under 18 years of age. See instructions for exceptions.
A.)
Attach W-2 and a copy of your birth certificate or a copy of your driver’s license. If you were under 18 part of the year have your
employer complete the Employer’s Certification at the bottom of this page.
❑ ❑ ❑ ❑ ❑
Refund of municipal income tax withheld on wages earned in a non-taxing community. (Attach a travel log listing dates and
B.)
places traveled for business, indicating the number of business days out
/260 days) See instructions.
❑ ❑ ❑ ❑ ❑
Unreimbursed Employee Expenses. (See instructions)
C.)
❑ ❑ ❑ ❑ ❑
Other (explain)
D.)
.
COMPUTATION OF OVERPAYMENT
$
1.)
1.)
Wages as reported on W-2 Form (Attach W-2’s) ....................................................................................................
2.)
$
2.)
Less Wages Not Subject to Tax .........................................................................................................................
$
3.)
3.)
Net Taxable Wages...........................................................................................................................................
$
4.)
Corrected Tax..................................................................................................................................................
4.)
$
Less:
5.) Tax Withheld .................................................................
6.) Prior Year Credit.............................................................
8.)
7.) Estimate Paid ................................................................
$
9.)
9.)
Refund Requested.............................................................................................................................................
I DECLARE UNDER THE PENALTIES OF PERJURY THAT THIS CLAIM (INCLUDING ANY ACCOMPANYING STATEMENTS), HAS BEEN
EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE AND CORRECT.
I AUTHORIZE THE DISCLOSURE OF THE INFORMATION HEREIN TO ANY LAWFUL TAXING AUTHORITY AFFECTED BY THE REFUND.
Taxpayer’s Signature
Date
TelephoneNumber (
)
-
.
Spouse’s Signature
Date
.
Preparer’s Signature
Date
TelephoneNumber (
)
-
.
EMPLOYER’S CERTIFICATION (To be completed by employer)
We have reviewed the above calculations and attachments and believe them to be true and correct.
I/We verify that no portion of said tax has been or will be refunded directly to the employee and that no adjustments to my/our withholding account
with the City of
have been or will be made for said tax.
Employer’s Signature
Title
Date
.
Company
F.E.I.D.
-
TelephoneNumber(
)
-
.
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