Form L-R - Application For Refund printable pdf download

CITY OF LAKEWOOD - Division of Municipal Income Tax

FORM L-R

12805 Detroit Ave. Lakewood, Oh 44107

Phone: 216.529.6620 Fax: 216.529.6099

Tax Year_______

Website:

APPLICATION FOR REFUND

Check Status:

Individual

Joint

IF MOVED DURING YEAR-

Your Social Security Number

Spouse's Social Security Number

____________________

_______________________

Enter date moved: ____/_____/____

Your first name and initial

Last Name

_____________________________________________

Enter former address:

If a joint return, spouse's first name and initial

Last Name

Address

Apt. No.

_____________________________________________

___________________________________________

Address

Apt. No.

City, State and Zip Code

_____________________________________________

___________________________________________

City, State and Zip Code

_____________________________________________

PLEASE CHECK BLOCK BELOW THE TYPE OF CLAIM FILED (SEE INSTRUCTIONS)

Refund of municipal income tax withheld for all or part of the year that applicant was under 18 years of age. See instructions for

exceptions. (attach W-2, and a copy of your birth certificate or a copy of your driver's license and have employer complete

verification below if under 18 part of year.)

Refund of Lakewood employment tax withheld on wages earned outside of Lakewood. (Attach a travel log listing dates and places

traveled for business, indicating the number of business days out _____/260 days) See instructions.

Unreimbursed Employee Expenses. (See instructions)

Other (explain)_____________________________________________________________________________________________

__________________________________________________________________________________________

Computation of Overpayment (see intstuctions)

Wages as reported on W-2 Form (Attach W-2's)…………………

1. $_________________________

Less Wages Not Subject to Tax…………………………………..

2. $_________________________

Net Taxable Wages…………………………………………………….

3. $_________________________

Corrected Tax (1.5%) ………………………………………………………4. $_________________________

Lakewood Tax Withheld………………………………………………..

5. $_________________________

Amount of overpayment…..………………………………………………… 6. $_________________________

Minus the amount you would like credited to your account………… 7. $_________________________

Net amount to be refunded…………………………………………….

8. $_________________________

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_______________Telephone Number____________

Spouse's Signature_____________________________ Date_______________

Preparer's Signature_____________________________Date______________Telephone Number_____________

EMPLOYER'S CERTIFICATION (To be completed by employer)

I/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 Lakewood have been or will be made for said tax.

Please complete the above Computation of overpayment (lines 1-8)

Employer's Signature____________________________Title________________________Date_____________

Company___________________________Federal ID #_________________Telephone (

)_____________

Form L-R - Application For Refund

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