Village Of Granville Income Tax Department Claim For Refund Form

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Village of Granville Income Tax Department
FOR TAX OFFICE USE:
CLAIM FOR REFUND
File Original with:
Granville Income Tax Department
141 E Broadway * PO Box 514
Granville, OH 43023
This form must cover one calendar year and one employer only.
FORM W-2 MUST BE ATTACHED.
1. Name of Applicant: ______________________________________________________________________________________
2. Present Address: ________________________________________________________________________________________
3. Social Security Number: _____________________________ City of Employment: __________________________________
4. Federal ID Number: ____________________________ (Employers only)
THE UNDERSIGNED HEREBY MAKES CLAIM FOR REFUND OF GRANVILLE VILLAGE TAX
5. In the amount of $______________________
6. While in the employ of (name & address where worked performed): _______________________________________________
7. For the Period (dates) From: __________________________
To: ________________________________
8. Resident address for this period: ____________________________________________________________________________
9. Reason For Refund: (fully explain and attach schedule of dates and locations worked out if applicable) ___________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
THE UNDERSIGNED FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED. TAXPAYER ALSO
UNDERSTANDS THIS INFORMATION MAY BE RELEASED TO TAX ADMINISTRATION OF THE CITY OF
RESIDENCE AND THE IRS.
Date _____________________ Signature _________________________________________ Phone ________________________
_________________________________________________________________________________________________________
CERTIFICATION OF EMPLOYER
I/we hereby certify that the above employee was employed by the undersigned during the period for which said employee makes
claim for refund and that the total amount of $_____________ was withheld for the year _______; that said employee was not
during the period claimed above, working inside the corporation limits of the Village; 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 refunded to said employee; and that no adjustment
has been or will be made in remitting taxes withheld to the Village of Granville.
____________________________________________
By: ________________________________________
Name of Employer
Signature of Officer
Date_____________ Federal ID # _____________________ Title __________________________ Phone___________________
NOTICE:
•
This refund may result in an amendment of Federal, State or other city tax returns.
•
Refunds of $10.00 or more are reported to the IRS.
•
Please allow 90 days for the processing of your refund request.
•
Refunds of less than $5.00 will NOT be processed.
SEE INSTRUCTIONS ON REVERSE SIDE

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