Claim For Refund Form - Income Tax Department - Pickerington - Ohio

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City of Pickerington
To be used only by individuals under 18 or by
Income Tax Department
non-residents who have had Pickerington
100 Lockville Road
taxes withheld erroneously
 
 
 
Pickerington, Ohio 43147
CLAIM FOR REFUND
This form can cover one calendar year and one employer only. A copy of form W-2 showing Pickerington
City tax withheld must be attached. Additionally, if claimant is under 18, a copy of birth certificate or
driver’s license must be attached.
NAME OF APPLICANT:
LAST NAME
FIRST NAME
MIDDLE
PRESENT ADDRESS:
SOCIAL SECURITY NO.:
CITY OF EMPLOYMENT:
REFUND IN THE AMOUNT OF $
WHILE IN THE EMPLOY OF:
FOR THE DATES FROM:
TO:
RESIDENT ADDRESS FOR THESE DATES:
REASON (EXPLAIN FULLY OR ATTACH WORK SCHEDULE/LOCATIONS):
CLAIMANT FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER.
TAXPAYER ALSO UNDERSTANDS THIS INFORMATION MAY BE RELEASED TO THE TAX
ADMINISTRATION OF THE CITY OF RESIDENCE AND/OR THE IRS.
SIGNATURE:
DATE:
PHONE NUMBER:
CERTIFICATION OF EMPLOYER
I/We hereby certify that the above employee was employed by the undersigned during the period during
which said employee makes claim for refund and that the total amount of $
was
withheld for the year 20
; that no portion of said tax withheld has been or will be refunded to said
employee; and that no adjustment has been made or will be made in remitting taxes withheld to the City.
NAME OF EMPLOYER
SIGNATURE OF OFFICER
DATE:
FID#:
TITLE:
PHONE:
NOTICE:
This refund may result in an amendment to Federal, State, or other city tax returns
Refunds of $10.00 or more are reported to the IRS
Please allow up to 90 days for processing of your refund request

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