Form L-Rev - Application For Refund Form - City Of Lakewood - Division Of Municipal Income Tax
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1
2CITY OF LAKEWOOD - Division of Municipal Income Tax
FORM L-REV
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)
A.
Refund because the employer continued to withhold Lakewood residence income tax after your move out of Lakewood
B.
Refund because the employer withheld more then 1% for Lakewood residence income tax
Computation of Overpayment (see intstuctions)
1.
Wages as reported on W-2 Form (Attach W-2)…………………
1. $_________________________
2.
Lakewood Tax Withheld as reported on W2………………………………………………..
2. $_________________________
3.
Lakewood Income Tax due
3. $_________________________
4.
Amount of overpayment…..………………………………………………………
6. $_________________________
5.
Minus the amount you would like credited to your account………… 7. $_________________________
6.
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 declare under the penalties of perjury that 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.
Employer's Signature____________________________Title________________________Date_____________
Company___________________________Federal ID #_________________Telephone (
)_____________
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