Fillable Form It-Ar - Application For Personal Income Tax Refund

Form It-Ar - Application For Personal Income Tax Refund - 2001

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IT-AR

(Rev 02/01)

PPLICATION FOR

ERSONAL

NCOME

EFUND

File this application in duplicate with:

Please type or print in ink.

Ohio Department of Taxation

P.O. Box 2476

Retain a copy for your records.

Columbus, OH 43216-2476

See important information and law on back.

Attn: Personal Audit

For calendar year _______ beginning __________________ ending ___________________

1. Name ________________________________________________________________________________________

2. Address _______________________________________________________________________________________

street or p.o. box

city

state

zip code

county

3. Social Security No. ___________________________ Spouse's Social Security No. ____________________________

4. Total amount of refund claimed $ _____________________

a. By payment of an Illegal or Erroneous Assessment:

Assessment Date: ________________

Assessment Serial No. _________________

___________________

b. By other Illegal or Erroneous Payment to Treasurer of State .............................................

___________________

c. Total Amount of Claim ......................................................................................................

___________________

5. State full and complete reasons for above claim. Attach additional sheets, if necessary.

6. Payment of the amount (line 4c) upon which this refund claim is based was made or included in the following

remittance(s): (include all payments made for the report year(s). Attach additional payment schedule, if necessary).

Type

Amount

Type

Amount

Tax Withheld

Tax Paid with Original Return

Estimated Tax Paid

Any additional Income Tax Paid

Total Payments

I hereby attest that I am the taxpayer(s) or his authorized agent. I declare under penalties of perjury that this return or claim (including any accompa-

nying schedules and statements) has been examined by me and to the best of my knowledge and belief is true, correct and complete.

The Individual(s) will be represented in this matter by

(complete, if known):

Name _________________________________________

Name(s) _______________________________________

Address _______________________________________

Signature ______________________________________

_____________________________________________

Date __________________________________________

For state use only