Application For Personal Income Tax Refund Form
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1IT AR
Rev. 5/04
Application for
Personal Income Tax Refund
• Please type or print in ink.
File this application with:
Ohio Department of Taxation
• Retain a copy for your records.
P.O. Box 2476
• See important information and law on back.
Columbus, OH 43216-2476
Attn: Personal Audit
For calendar year beginning
Ending
Name
Street address
City, state, ZIP code
Social security no.
Spouse’s Social Security no.
Total amount of refund claimed $
1. by payment of an illegal or erroneous assessment………………………………………………….
$
Assessment date:_____
______ assessment serial no. ____
______
2. by other illegal or erroneous payment to Ohio Treasurer of State………………………………….
$
3. total amount of claim……………………………………………………………………………….
$
State full and complete reason for above claim. Attach additional sheets, if necessary.
Payment of the amount upon which this refund claim is based was made or included in the following remittance(s)
(include all payments made for the report year(s) and attach additional payment schedule, if necessary):
Type
Amount
Type
Amount
Tax Withheld
$
Tax paid with original return
$
Estimated tax paid
$
Any additional income tax paid
$
Total Payments:
$
Person responsible for the filing of this refund application. I declare under penalty of perjury that I’m the taxpayer or that I’m an authorized agent of
the taxpayer having knowledge of the relevant facts in this matter to file this refund application.
Signature
Date
Telephone no.
Contact person (if different from the person above responsible for filing this refund application).
Name
Title
Street address
Fax no.
Daytime phone no.
City, state, ZIP code
E-mail address
For state use only
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