Form 10a - Application For Municipal Income Tax Refund
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1
2REGIONAL INCOME TAX AGENCY
FORM
Application For Municipal Income Tax Refund
10A
–
–
Social Security Number
Tax Year of Claim
Tax Payer Name
Address #
Suite
Street Name
City
–
State
Zip
1. Employer Name
2. Municipality of Employment
$
,
,
.
3. Amount of Income Exempt from Tax (Check Appropriate Box Below)
$
,
,
.
4. Amount of Gross Refund Claimed
$
,
,
.
5. Amount You Want Credited to Your Individual Account
–
–
Social Security Number
$
,
,
.
6. Net Amount to be Refunded (Subtract Line 5 from Line 4)
CHECK BLOCK BELOW TO INDICATE REASON FOR CLAIM AND ATTACH ALL REQUIRED DOCUMENTATION
(see instructions on page 3)
1.
Under 18. D.O.B.
/
/
ATTACH W-2 AND PROOF OF BIRTHDATE.
m
m
d
d
y
y
2.
Unreimbursed business expenses. ATTACH COPY OF W-2 AND 2106 EXPENSE.
3.
Other.
Page 1
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FORM 10A
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