Claim For Refund Form printable pdf download

Claim For Refund Form

LOUDONVILLE INCOME TAX

Village of Loudonville

156 N. Water Street

P.O. Box 115

P.O. Box 150

Loudonville, OH 44842

419-994-3282

Phone: 419-994-3214 Fax: 419-994-3213

CLAIM FOR REFUND

1. Name of Applicant:______________________________________________

2. Present Address: ______________________________________________

_____________________________________________

3. Social Security #: _________________________

The undersigned hereby makes claim for refund of Loudonville Village Income

Tax:

4. In the amount of $_________________

5. While in the employ of ___________________________________________

6. For the period _________________________________________________

7. Reason (Explain fully and attach W-2):______________________________

_____________________________________________________________

and further states that said refund has not yet been received by him/her.

Date:_________________

Signed:________________________________

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CERTIFICATION OF EMPLOYER

I hereby certify that the above employee was employed by the undersigned during the period

of which said employee makes Claim for Refund and that the total amount of $_________

was withheld during the year ______; and that said employee was not a resident of the

Village of Loudonville at the time the tax was withheld nor did the employee work within the

Village of Loudonville; and that no portion of said tax withheld has been or will be refunded to

said employee; and that no adjustment has been or will be made in remitting taxes withheld to

the Village of Loudonville.

Signature:_______________________ Title:___________________________

Date:_____________________

Claim For Refund Form