Form 10a - Application For Municipal Income Tax Refund (Page 2 of 2) in pdf

EMPLOYER’S CERTIFICATION/COMPUTATION must be signed by the employee’s supervisor or other responsible

representative of the employer who has knowledge that the information given is true and correct.

I / We verify that during the year _____________ I / We withheld municipal income tax for the City/Village of

________________________________from the above named employee in excess of his liability for the tax based

on the following computations:

A. From W-2, total wages $ ____________________________ on which_______________________________

(City/Village)

tax withheld was ....................................................................................... $ ____________________________

Work performed in city of _____________________________ subject to tax

(City/Village)

Taxable income $ ________________________ x __________ ...........$ _____________________________

(Tax Rate)

Amount of overpayment............................................................................$ _____________________________

B. Basis for refund

____________________________________________________________________________________________

C. According to our records, this employee’s address for the period covered by the claim was

____________________________________________________________________________________________

I / We verify that no portion of said tax has been or will be refunded directly to the employee and that no

adjustments to my / our withholding account with the City / Village of ___________________________________

have been or will be made for said tax.

SIGNED

________________________________________________________________________________________

Name

Title

Phone #

Date

________________________________________________________________________________________

Print Name

Title

I certify that the facts and allegations contained on this form and on any accompanying schedules are true. I

understand that this information may be released to the tax administration of the city of residence and the I.R.S.

TAXPAYER’S SIGNATURE

________________________________________________________________________________________

Name

Day Phone

Eve Phone

Date

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Form 10a - Application For Municipal Income Tax Refund Page 2