Form Wcwt-5 - Application For Refund Of Wilmington City Wage Tax - 2014 Page 4
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SECTION 3 - EMPLOYER CERTIFICATION
(CERTIFICATION REQUIRED FOR PROCESSING)
CERTIFICATION BY EMPLOYER: I certify that the facts shown above supporting Employee’s Claim for allocation and non-taxable
income are correct based on available payroll records.
FEI/FN
A
U
T
H
O
R
Z I
E
D
O
F
F
C I
A I
L
T (
y
p
e
r o
r P
n i
) t
T
E
L
E
P
H
O
N
E
#
A
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D
O
F
F
C I
A I
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Questions
. 1
D
d i
y
o
u
f
e l i
f
r o
a
2
013
e r
u f
n
d
?
Y
e
s
No
2. If yes, have you since changed your address?
Yes
No
Signature/Identification
TAXPAYER SIGNATURE
DATE
SIGNATURE OF PREPARER OTHER THAN TAXPAYER
DATE
S
O
C
A I
L
S
E
C
U
R
T I
Y
N
U
M
B
E
R
N
A
M
E
ADDRESS
TELEPHONE NUMBER
IDENTIFYING NUMBER
SECTION 4 - PROCESSING (TAX OFFICE USE ONLY)
A/P CLAIM
A/P CLAIM
WAGE
EMPLOYER’S
REFUND AMOUNT
NUMBER
BATCH NUMBER
BATCH NUMBER
ACCOUNT NUMBER
P
R
O
C
E
S
S
E
D
B
Y
A
P
P
R
O
V
E
D
B
Y
-
I D
I V
I S
O
N
H
E
A
D
DEPARTMENT HEAD
APPROVAL (OVER $10,000)
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