Form Itb 69 - Income Tax Refund Claim
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1
2INCOME TAX REFUND CLAIM
TAX OFFICE USE:
INCOME TAX DIVISION, CITY HALL
Claim # _____________________
SPRINGFIELD, OHIO 45502
FOR
Approved____________________
Name ______________________________________________________
Account # _________________________
( type or print full name, do not use initials )
Present Address ______________________________________________
Social Security #____________________
( street )
____________________________________________________________
F.I.D.#____________________________
( city and zip code )
Address During Period Covered by Claim, if different from present address:
From
To
__________________________________________________________________
____________
_______________
( street )
__________________________________________________________________
( city and zip code )
AMOUNT CLAIMED $ _______________
REFUND REQUESTED IS FOR OVERPAYMENT:
A. ____________( as shown on Return ) or,
B. ____________( excess withholding )
A. OVERPAYMENT INDICATED ON _____________ SPRINGFIELD INCOME TAX RETURN
B. OVERPAYMENT OF __________ SPRINGFIELD TAX WITHHELD FROM WAGES ( See Instructions )
List Employer(s) Name(s) and Address(es)
Gross
Amount
( Wage W-2’s showing tax withheld must be attached )
Wages
Withheld
Reason for refund: ( Claimant must provide all pertinent information and facts on which claim is based explaining
fully and concisely why Income Tax should be refunded )
AFFIDAVIT: The undersigned states that all facts and figures given are true and complete to the best of his/her knowledge
and belief, that no such refund has previously been claimed or received by him/her; and understands that this information
may be released to the Internal Revenue Service.
Signed______________________________________ Title______________________________Date______________
For Office Use Only:
APPROVED FOR PAYMENT
______________________________________
________________________________________
_____________
( City Manager )
( Finance Director )
( Date )
Form ITB 69 ( Rev. 1/00 )
EMPLOYER CERTIFICATION AND INSTRUCTIONS ON PAGE TWO
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