Form Tricota/ref/12 - Individual Refund From

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INDIVIDUAL REFUND FORM - YEAR _ _ _
PLEASE READ THE INSTRUCTIONS ON BACK BEFORE COMPLETING.
1. Applicant's name
2. Soc. Sec. N o . - - - - - - - - - -
3. Current Address
C i t y - - - - - - - - - - -
S t a t e - - - - - - -
Zip C o d e - - - - - -
Phone ___________ _
4. Were you ever a resident of the Municipality from which refund is requested? _ _ _
If yes, give dates:
THE UNDERSIGNED HEREBY MAKES CLAIM FOR REFUND OF INCOME TAX
FROM THE MUNICIPALITY OF
OHIO.
5. For tax year of
(one year per form)
6. In the amount o f $ - - - - - -
7. While employed by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
8.Comp~~addffissclwo~~cation
___________________________________
~
9. For the period of ( d a t e s ) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
10.Re~de~addffissfur~~period
________________________________________________________
~
11.
Reasonfurffiquest(ex~~nfWiy)
_________________________________________ _
jAND FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER
Sworn to and subscribed before me this
_ _ _ _ Day of
, _ _ _
Signature Taxpayer Claiming Refund
Signature Officer Administering Oath
Title
---------------------------------------------------------------~-
CERTIFICATION OF EMPLOYER
I hereby certify that the above employee was employed by the undersigned during the period for which said employee makes claim for
refund and that during said period
$
was withheld from the earnings paid said employee; that the total amount of
$ _ _ _ _
was withheld for the year
; that said employee was not, during the period claimed above, working inside corporate limits of the
Municipality of
, Ohio and that no portion of said tax withheld has been or will be refunded to said employee; and that
no adjustment has been or will be made in remitting taxes withheld to the Municipality of
, Ohio.
(Name of Employer)
By: _ _ _ _ _ _
Date--------------
TRICOTA/REF/12
(Title)

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