Form Pte Ref - Application For Pass-Through Entity Tax Refund
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1
2PTE REF
Rev. 9/14
Reset Form
Application for Pass-Through Entity Tax Refund
Please check one:
File this application with:
Please type or print in ink.
Ohio Department of Taxation
IT 4708
Employment Tax Division
Retain a copy for your records.
P.O. Box 2476
See important information and law on
IT 1140
Columbus, OH 43216-2476
page 2.
IT 1041
Fax (614) 466-1582
For year beginning
, 20
and ending
, 20
1. Name
2. Address
3. City, state, ZIP code
4. FEIN/SSN
5. Amount of refund claimed
a. By payment of an illegal or erroneous assessment:
Assessment date
Assessment serial #
$
b. By other payment to Ohio Treasurer of State ................................................................................ $
c. Total amount of refund claimed (prior to calculation of interest) .................................................... $
6. State full and complete reasons for above claim. Attach additional sheets, if necessary.
7. Payment of the amount upon which this refund claim is based, was made or included in the following remittance(s) (include
all payments made for the tax year). Attach additional payment schedule, if necessary:
Amount
Date
Amount
Date
=
Total Payments
$
Person responsible for the fi ling of this refund application. I declare under penalty of perjury that I am the taxpayer or that I am
an authorized agent of the taxpayer, having knowledge of the relevant facts in this matter to fi le this refund application.
Name
Title
E-mail
Signature
Date
Phone no.
Contact person (if different from the person above responsible for fi ling this refund application).
Name
Title
Firm name
Daytime phone no.
Street address
Fax no.
City, state, ZIP code
E-mail address
For state use only
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