Application For Income Tax Refund - City Of Cleveland Heights Page 2
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2EMPLOYER'S CERTIFICATION - TO BE COMPLETED BY EMPLOYER:
CITY OF CLEVELAND HEIGHTS
P.O. BOX 18850
CLEVELAND HEIGHTS, OH 44118-0850
(216) 291-3978
I/We certify that during 19______, I/We withheld the City of Cleveland Heights Income Tax
from ________________________________________(name) employee in excess of their liability
for the tax based upon the following data:
COMPUTATION OF OVERPAYMENT (INCLUDE COPY OF W-2(S)):
A.
SALARIES, WAGES, ETC., PAID $
ON WHICH
CLEVELAND HEIGHTS TAX WAS WITHHELD WAS
(a)$
INCOME ACTUALLY EARNED IN CLEVELAND HEIGHTS
SUBJECT TO CLEVELAND HEIGHTS INCOME TAX WAS
$
(X 2%) =
(b)$
OVERPAYMENT................(a - b = c)................................................
(c)$
B.
BASIS FOR REFUND (EMPLOYER MUST PROVIDE ALL PERTINENT
INFORMATION AND FACTS ON WHICH CLAIM IS BASED.) EXPLAIN
METHOD AND/OR SHOW COMPUTATIONS USED TO DETERMINE INCOME
EARNED IN CLEVELAND HEIGHTS.______________________________________
C.
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 CLEVELAND
HEIGHTS HAVE BEEN OR WILL BE MADE FOR SAID TAX.
SIGNED
/
/
/
Name
Title
Phone #
Date
/
Print Name
Title
EMPLOYER'S FEDERAL ID#_______________________
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