Village Of Granville Income Tax Department Claim For Refund Form Page 2

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GENERAL INSTRUCTIONS
INSTRUCTIONS FOR COMPLETING CLAIM FORM
A. WHO SHOULD FILE THIS CLAIM:
1. A non-resident who performs less than 100% service
Line 1: Print full name (first name, last name and
within the corporation limits of the city indicated
middle initial).
and whose village income tax has been withheld by
his employer.
Line 2: Print current full address including city, state,
and zip.
2. An employer who has remitted to the Village of
Granville in error, income tax withheld from his
Line 3. Clearly show social security number and city
employees.
where you worked.
B. This claim must set forth in detail each ground upon
Line 4. To be used by EMPLOYERS ONLY who are
which it is made, and facts sufficient to apprise the
Income Tax Division of the exact basis thereof.
applying for refund of withheld income tax
remitted to the Village of Granville in error.
C. In the case of an employee, claimant’s copy of Form W-
2 must be attached. Claimant should use W-2 copy
Lin 5: Amount of refund applied for.
provided for local or city taxes since W-2 form will not
be returned.
Line 6. Give full name of employer and address where
physically employed during period covered by
D. The working year consists of 260 days (Saturday and
this claim.
Sunday are not considered working days). Sick,
vacation and holiday pay should be prorated in same
Line 7: State the period by dates that this claim covers
proportion as time worked out of the city indicated. (260
minus sick, vacation and holidays equals days worked.
within a calendar year. A separate claim must
Total wages divided by days worked equals wages per
be filed for each year involved.
day. This, times days worked outside city limits, equals
non-liability).
Line 8: Show resident address for period of time
covered by the claim.
E. Certification of employer must be completed by him or
his authorized officer or agent.
Line 9: Explain fully and concisely why Village
income tax should be refunded. ATTACH
F. An employer applying for refund of city income tax paid
SCHEDULE OF DATES AND LOCATIONS
in error in excess of the amount of tax withheld by him,
WORKED OUTSIDE THE CITY and any
must file an amended withholding form showing
accurate figures for the quarter so affected.
other pertinent information if the space
provided is insufficient.
____________________________________________
IF ALL INSTRUCTIONS ARE NOT FOLLOWED,
CLAIM WILL NOT BE APPROVED
AND WILL BE RETUNED
____________________________________________
REFUND REQUESTS WILL NOT BE HONORED
beyond three years from the date of the taxes were
due.

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