Form 83-A272a - Wage Tax Refund Petition Salary/hourly Employees 2006
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CITY OF PHILADELPHIA
DEPARTMENT OF REV ENUE
YEAR
WAGE TAX REFUND PETITION
REFUND UNIT
SALARY/HOURLY EMPLOYEES
2006
1401 JOHN F. KE NNEDY BOULEV ARD - ROOM 580
(Not to be used by Commissioned Employees)
PHILADELPHI A, PA 19102
EMPLOYEE'S NAME (PLEA SE P RINT)
SOCIAL SECURITY NUMBER
OFFICE USE ONLY
HOME ADDRESS
EMPLOY ER IDENTIFICATIO N NUMBER (EIN)
DAYTIME TELEPHONE NUMBER
CITY
STATE
ZIP CODE
IF PA RTIAL Y EAR:
From__________ _______ To_____ ____________
EMPLOY ER
OCCUPATION
EMPLOY EE'S WO RK LO CATION
SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM
.00
1. GROSS COMPENSA TION
DAYS
2. COMPUTATION OF TAXABLE COMPENSATION AND/OR ALLOWABLE EXPENSES
1
365 Days/2920 Hours
A. NUMBER OF DAY S/HOURS
HOURS
B. NON-WORKDAYS/HOURS (TOTAL OF WEEKEND, VACATION, HOLIDAY, AND SICK LEAVE)
0
Days/Hours
C. NUMBER OF ACTUAL WORKDAYS/HOURS (BASE___ ________ _OVERTIME___________ _)
1
Days/Hours
(LINE 2A - LINE 2B) IF COMPUTING OVERTIME, SEE INSTRUCTIONS ON REVERSE.
0
Days/Hours
D. NUMBER OF ACTUAL DAYS/HOURS WORKED OUTSIDE OF PHILADELPHIA IN LINE 2C
E. PERCENTAGE OF TIME WORKED OUTSIDE PHILADELPHIA (LINE 2D DIVIDED BY LINE 2C)
0.0000%
.00
0
F. NON-TAXABLE COMP ENSATION EARNED OUTSIDE PHILADELPHIA (LINE 1 X LINE 2E)
G. DEDUCTIBLE, NON-REIMBURSED BUSINESS EXPENSES FROM WORKSHEET ON
.00
INSTRUCTIONS PAGE. ATTACH A COPY OF FEDERAL FORM #2106
H. NON-TAXABLE INCOME AND/OR DEDUCTIBLE EMPLO YEE BUSINESS EXPENSES
.00
0
(LINE 2F + LINE 2G)
.00
0
3. TAXAB LE COMPENSATION (LINE 1 MINUS LINE 2H)
RESIDENT
4.
RESIDENTS: LINE 3 X .04301
.00
TAX DUE
NON-RESIDENTS: LINE 3 X .037716
NONRESIDENT
.00
5. WAGE TAX WITHHELD PER W-2(S)
.00
6. REFUND REQUESTED (LINE 5 MINUS LINE 4)
0
EMPLOYER CERTIFICATION
I certify that the facts shown ab ove supporting employee's claims are correct based on available payroll records. Individuals serving as authorized
official signatories should be familiar with employee's time and attendance, as well as applicable Wage Tax Regulations. Income Tax Regulations
Section 401 through 404 requires that the employer properly withhold and allocate wages for tax purposes. General Regulation Section 306 (2)
provides that the employer, for and on behalf of the employee, requests the refund.
AUTHORIZED OFFICIAL SI GNATURE
PRINTED NAME
DAYTIME TELEPHONE NUMBER
EMPLOYEE CERTIFICATION
I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my knowledge
and belief. I understand that if I knowingly make any false statements herein, I am subject to such penalties as may be prescribed by City Ordinance.
TAXPA YER SI GNATURE
DATE
DAYTIME TELEPHONE NUMBER
There are further directions for both the Employer as well as the Employee on the other side of this form.
Please read them before completing this document. Completed petition must include:
W-2 showing Federal, State, Medicare and Local wages
Signature of Employee and Employer
IRS form 2106 if claiming expenses (including breakdown of line 4)
83-A272A Rev. 8/26/2006
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