Form Itb 69 - Income Tax Refund Claim (Page 2 of 2) in pdf

INSTRUCTIONS

1. All claims must be properly signed.

2. An employee who is claiming a refund of taxes withheld must list his/her employer’s names and addresses and attach

his/her wage statement( s ) showing Springfield tax withheld ( Forms W-2 ).

3. A claim for refund by persons under 18 years of age must include verification giving the exact birthdate of claimant

(i.e., photocopy of birth certificate or driver’s license ).

4. The average working year consists of 260 days ( Saturday and Sunday are not considered working days ).

5. Training sessions, seminars, meetings, temporary or casual employment, although they may be outside the city, do

not constitute changes in work situs and are not factors in determining time worked out of the city.

6. Employer’s certification must be completed by authorized officer or agent.

7. Attach copies of Federal forms as may be applicable.

8. No refund of less than one dollar ( $1.00 ) will be made.

9. Refund requests will not be honored beyond three ( 3 ) years from the date the taxes were due.

10. Please allow ninety ( 90 ) days for processing your refund request.

NOTE: INCOMPLETE CLAIMS CANNOT BE APPROVED AND WILL BE RETURNED TO CLAIMANT.

COMPLETE BELOW ONLY IF YOU ARE A NON-RESIDENT CLAIMING A REFUND OF CITY INCOME TAX WITHHELD IN

EXCESS OF YOUR ACTUAL LIABILITY.

Compute the amount to be entered as taxable city income by multiplying the total compensation by the ratio of actual days

worked.

260

( A ) TOTAL DAYS AVAILABLE………………………………..……………………….

( B ) LESS: VACATION DAYS …………………………………………………………..

( C ) LESS: SICK DAYS ………………………………………………………………….

( D ) LESS: HOLIDAYS ………………………………………………………………….

( E ) LESS: OTHER TYPES NON-WORKING DAYS ………………………………..

( F ) TOTAL AVAILABLE WORKING DAYS …………………………………………..

( G ) TOTAL AVAILABLE WORKING DAYS …………………………………………..

( H ) DAYS WORKED OUT OF TOWN ( attach log ) …………………………………

( I ) DAYS ON JOB IN SPRINGFIELD ..………………………………………………

COMPUTATION

( Line I )

( Line F )

( Total Income )

(Taxable City Income)

Springfield Tax Rate 2% …………………………………………………………

Net Tax Due ( applicable rate x Springfield Taxable Wages ) ……………... $

Less: Income Tax Withheld ………………………………………………….… $

REFUND CLAIMED ………………………………………………………... $

EMPLOYER’S CERTIFICATION ( to be completed by employer )

The employee named on the first page of this form has claimed a refund for the reasons listed. As any refund to one of

your employees will result in a debit from your withholding tax account, we require verification of this claim.

Employer Comments:

AFFIDAVIT I/We hereby certify that ______________________ ( employee ) was employed by the undersigned during the

period for which said employee makes claim for refund and that the total amount of $ ____________ was withheld for the

year ( s ) _________; that said employee was not working inside the corporate limits of Springfield during the period

claimed; and that no portion of said tax withheld has been or will be refunded directly to the employee, and no adjustment

in withholding remittance has been or will be made.

I further declare that the information contained herein is true and correct to the best of my knowledge and belief and that I

am authorized to provide this information.

Authorized Name ___________________________________________ Title ___________________ Date ___________

Employer __________________________________________________Telephone ______________________________

Form ITB 69 ( Rev. 1/00 )

EMPLOYER CERTIFICATION AND INSTRUCTIONS ON PAGE TWO

Form Itb 69 - Income Tax Refund Claim Page 2

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