Form Afa-Int - Application For Adjustment Of City Tax - City Of Greenville

FOR TAX OFFICE

USE ONLY:

CITY OF GREENVILLE

YEAR

: _____________

APPLICATION FOR ADJUSTMENT OF CITY TAX

ACCT: ___________

(Form AFA-INT)

TO BE FILLED IN BY EMPLOYEE:

Employee name

Address (your check will be sent here)

Employee Social Security Number

Employee Phone#

I hereby certify that I have kept a true and accurate record of my services performed for: _____________________

___________________________ for the year beginning ___________________ and ending __________________

and can verify that the percentage of my time worked outside the City of Greenville was ___________%. I further

certify that during the above period, I was not a resident of said Greenville, Ohio.

By signing this form, I authorize the City of Greenville to contact the employer representatives regarding this

adjustment request.

Employee signature

Date

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EMPLOYER’S CERTIFICATION:

(Note: Section 1 and 2 both should be completed. If personnel/payroll and supervisor are one in the same, complete only Section 1)

1.

(Name of authorized personnel/payroll)

(Personnel/payroll signature)

(Date)

(Phone number)

(Extension)

2.

(Name of supervisor)

(Supervisor signature)

(Date)

(Phone number)

(Extension)

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REFUND WILL NOT BE ISSUED WITHOUT W-2 FORM AND AUTHORIZED SIGNATURES.

SEND COMPLETED FORM TO: INCOME TAX DEPARTMENT

100 PUBLIC SQUARE

GREENVILLE, OH 45331

QUESTIONS? Call 937-548-5747 Monday – Friday 8:00 a.m. to 4:30 p.m.

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DO NOT WRITE IN SPACE BELOW; FOR TAX OFFICE USE ONLY

REFUND YEAR _________________

APPROVED BY _________________

REFUND AMOUNT $________________

REF. # ______________________