Form 07-1466 - Employee Application For Refund

Form 07-1466 - Employee Application For Refund - 1999

EMPLOYEE APPLICATION FOR REFUND

Alaska Department of Labor

Telephone: 907-465-2757

and Workforce Development

For Calendar Year ______________

Toll Free: 1-888-448-3527

Employment Security Tax

Fax:

907-465-2374

P.O. Box 25509

Juneau, AK 99802-5509

Please read instructions before completing.

You are eligible for a refund of excess employee contributions to the Unemployment Insurance Trust Fund if:

• you were employed by two or more employers in a calendar year,

• you had withholdings from your wages that exceed the maximum annual employee tax,

• this application is filed by December 31 of the year following the year in which the deductions were made,

• you provide copies of your Statement of Deductions (W-2’ s) from each employer you worked for during the year, and

• your overpayment is $5.00 or greater.

Name: ____________________________________________________ Social Security Number:

__________________________

Address: __________________________________________________ Daytime Telephone:

____________________________

City: ______________________________________________________ State: __________ Zip: ___________________________

Agency

Employee

Name of Your Employers

Use

Gross Wages

Contributions

Agency Use Only

(Please type or print clearly.)

Only

Received

Deducted

I certify that the above information is true and

TOTALS

correct to the best of my knowledge and belief.

Applicant Signature: ___________________________________

LESS

Date: ___________________________________

REFUND

Form 07-1466 (11/99)

Form 07-1466 - Employee Application For Refund - 1999