Fillable Refund Request Form printable pdf download

CITY OF TROY INCOME TAX DIVISION

REFUND REQUEST FORM

100 S MARKET ST, TROY OH 45373

TAX YEAR __________

(937) 339-3861

(Complete a separate form for each tax year)

PART A

To be completed by Applicant

(General Instructions are on the reverse of this form)

NAME:_________________________________________________

ACCOUNT #:_______________________________

SOCIAL SECURITY #:_______________________

FEDERAL ID#:_____________________________

PRESENT ADDRESS:___________________________________________________________________________________

ADDRESS DURING CLAIM PERIOD:_____________________________________________________________________

DATES YOU RESIDED AT THIS ADDRESS: FROM:______________________ TO:______________________

CITY OF EMPLOYMENT:_______________________________________________________________________________

EMPLOYER’S NAME:__________________________________________________________________________________

EMPLOYER’S ADDRESS:_______________________________________________________________________________

ADDRESS WHERE WORK WAS PERFORMED:____________________________________________________________

APPLICANT’S COMPUTATION OF AMOUNT CLAIMED:

A. Total Troy Taxable Income

$____________________

(From computation on reverse side of form)

B. Troy Tax Due at 1.75%

$____________________

C. Troy Tax Withheld

$____________________

(From W-2’s—Be sure to attach all W-2’s to claim)

D. REFUND CLAIMED

$____________________

(Line C minus Line B)

EXPLANATION OF REFUND (Give brief explanation and show computations on back. Attach travel log if applicable):

_____________________________________________________________________________________________________

By signing this claim form, I certify that all facts and figures are true and complete to the best of my knowledge, and that no

such refund has previously been claimed or received by me for the period covered by this claim. I authorize the City of Troy

to release this information to my city of residence or employment.

SIGNED:__________________________________ DATE:______________ DAYTIME PHONE:____________________

PART B

CERTIFICATION OF EMPLOYER To be completed by employer

I / We hereby certify that during the tax year __________, City of Troy income tax was withheld from the above named em-

ployee in excess of liability for the tax based on the following:

Gross salaries, wages, etc. paid $____________________

Troy Tax Withheld

$_______________

Income earned in Troy

$____________________

Tax due at 1.75%

$_______________

Basis of refund—Employer must provide all pertinent information and facts on which claim is based. Explain

method used and show all computations used to determine income earned in Troy:

________________________________________________________________________________________

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

________________________________________________________________________________________

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

or will be made to my / our withholding account with the City of Troy.

PRINTED NAME:_____________________________________SIGNATURE:_____________________________________

TITLE:_____________________________ DATE:_________________

DAYTIME PHONE:______________________

Refund Request Form

Related Articles

Related forms

Related Categories