Form E-1r - Individual Earnings Tax Refund Request November - 2016

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CITY OF ST. LOUIS
CALENDAR
Form E-1R
YEAR
INDIVIDUAL EARNINGS TAX
(Rev 11/1 )
REFUND REQUEST
201
Telephone: (314) 622-3292
Fax: (314) 622-4847
PLEASE PRINT YOUR NAME AND
ADDRESS IN THE SPACE BELOW
Social Security Number:
Telephone Number:
Email Address:
A COPY OF EACH W-2 MUST ACCOMPANY THIS RETURN.
Please see instructions on the reverse side.
1.
Please report salaries, wages, etc. from box 1 on each W-2.
A
$
B
$
C
$
D
$
$
2.
Gross Salaries, Wages, etc. (total of lines A, B, C & D)
3.
Non-Residency Deduction (complete formula on the reverse side)
$
$
4.
Net Taxable Earnings (subtract line 3 from line 2)
5.
Earnings Tax (1% of line 4)
$
$
6.
Earnings Tax Withheld (from box 19 on each W-2)
7.
Refund Due (subtract line 5 from line 6) Refund claims under $1.00 will not be issued.
$
Pursuant to the Revised Code of the City of St.Louis, §5.22.100, the Collector of Revenue or his duly authorized agent has
the authority to audit the facilities or tax returns of an employer or taxpayer. I declare this return has been examined by me
and is true, correct and complete to the best of my knowledge and belief.
(Date)
(Signature)
(Typed or Printed Name)
(Preparer)
(Preparer EIN)
(Preparer Telephone)
Please mail all returns to:
GREGORY F.X. DALY
COLLECTOR OF REVENUE
1200 MARKET STREET, ROOM 410
ST. LOUIS, MO 63103

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