Medicare Tax Refund Request Form printable pdf download

The Commonwealth of Massachusetts

Office of the Comptroller

One Ashburton Place, Room 901

Boston, Massachusetts 02108

MEDICARE TAX REFUND REQUEST FORM

Please complete, sign and submit this form to request a Medicare tax refund from the Office of the Comptroller.

Departments must submit one Medicare Tax Refund Request form for every tax year the employee is due a

refund. Please keep a copy of this form in the employee ’s personnel file at your department ’s payroll office for

auditing purposes.

Employee Name:_________________________________________________ Employee ID #: __________________

(Print Employee’s Name)

(Print Employee’s ID)

Employee SSN: __________________________________________________Department:______________________

(Print Employee’s Social Security Number)

(Print 3-letter Department code)

Dept Contact Name: ______________________________________________Tel #: ___________________________

(Print Name of Person filling out form and their telephone number)

Email Address of Dept Contact: _____________________________________________________________________

Medicare Tax Refund Request

Total Amount of

Amount of Medicare

Medicare Wages: $_________________________________

tax refund (1.45% of wages): $________________

(Enter total amount of Employee’ s Medicare Wages)

(Calculate 1.45% of Employee’ s Medicare Wages)

If refund is for the current tax year, check this box and indicate the tax year in the space provided below:

Current Tax Year

For Tax Year: __________________

Departments must include a screen print of the employee’ s Medicare tax year-to-date balance with each current tax year

request. The year-to-date tax balance can be found in the HR/CMS Tax Balance panel under tax class FICA Med Hospital

Ins/EE (Navigation: Go/Compensate Employees/Maintain Payroll Data/Inquire/Tax Balances).

If refund is for a prior tax year, check this box and indicate the tax year in the space provided below:

Prior Tax Year

For Tax Year: ___________________

Departments must include completed Forms W-2C and W-3C and copies of prior year W2s with each prior tax year request.

Instructions for filing W-2Cs and W-3Cs can be found in the Comptroller’ s Fiscal Year Policy memo 2001-12 on the

Comptroller’ s website:

Medicare Tax Refund Request Form 2/22/01

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Medicare Tax Refund Request Form