Form Wt Ar - Application For Employer Withholding Tax Refund Form - Ohio Department Of Taxation

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WT AR
Reset Form
Rev. 1/14
Application for Employer Withholding Tax Refund
File this application in duplicate with:
Please type or print in ink.
Ohio Department of Taxation
Retain a copy for your records.
P.O. Box 2476
See important information and law on
Columbus, OH 43216-2476
back.
Attn: Employer Withholding Unit
Check the box next to the withholding tax type:
State income tax
School district income tax
For the income tax withholding period(s)
1. Name of taxpayer
2. Address
Street or P.O. box
City
State
ZIP code
County
3. Ohio withholding account number
Federal employer identifi cation number
4. Total amount of refund claimed
a. By payment of an illegal or erroneous assessment
Assessment date
Assessment serial number
$
b. Other illegal or erroneous payment to Ohio Treasurer of State
$
c. Total amount of claim
$
5. State full and complete reasons for above claim. Attach additional sheets, if necessary.
6. Payment of the amount upon which this refund claim is based was made or included in the following remittance(s): (Include
all payments made for the report year(s). Attach additional payment schedule, if necessary.)
Type
Amount
Tax paid with forms IT 501 and IT 941 (or SD 101 and SD 141)
$
Any additional tax paid
$
Total payments
$
I hereby attest that I am the taxpayer(s) or his authorized agent. I declare under penalties of perjury that this return or claim
(including any accompanying schedules and statements) has been examined by me and to the best of my knowledge and
belief is true, correct and complete.
The taxpayer(s) will be represented in this matter by (complete, if known):
Name
Signature
Date
Title
Telephone
Fax
Address
E-mail
For state use only

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