Medicare Tax Refund Request Form (Page 2 of 2) in pdf

Medicare Tax Refund Request Form Page 2

Reason for Refund:

(Please indicate the reason why the Medicare tax refund is being requested)

Signatures:

The undersigned agree that a Medicare tax refund is owed to the employee for the tax year and amount indicated on this

form.

The Employee, under penalties of perjury, certifies that he/she has not and will not claim a refund or credit for the

overpaid Medicare taxes on their personal income taxes for the tax year indicated on this form.

Employee Signature: _____________________________________________________Date: ____________________

The Department Payroll Director, under penalties of perjury, certifies that the employee requesting the refund was hired

by a Commonwealth employer prior to April 1, 1986, has had no break in service during their employment with the

Commonwealth, and therefore is exempt from Medicare tax withholding for the tax year indicated on this form.

Department

Payroll Director Signature: ________________________________________________ D ate: ____________________

Please submit completed form and required documentation to:

Office of the Comptroller

Payroll Unit

1 Ashburton Place, 9

floor

Boston, MA 02108

ATT: Silas Shah

If you have any questions please contact Silas Shah at 617-973-2339 or by email:

Silas.Shah@state.ma.us

Medicare Tax Refund Request Form 2/22/01

Page 2 of 2

Medicare Tax Refund Request Form Page 2