Form Osps.99.13 - Tax Refund Certification
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TAX REFUND CERTIFICATION
Use this form to document the employee’s choice for receiving a refund of social security and
Medicare taxes resulting from a Corrected W-2.
Employee Name
Employee SSN
Employee Address
OREGON STATEWIDE
Agency No.
Agency
Agency Phone Number
PAYROLL SERVICES
(OSPS)
Agency Address
EIN
(503) 378-3518 fax
93-1070707
E-mail:
OSPS.Help@oregon.gov
Corrected W-2 Detail
Online Resource Center:
Reason for Corrected W-2
INSTRUCTIONS TO
Tax Year Being Corrected
2016
EMPLOYEES:
Original Amount
Corrected Amount
Difference
Complete this form online
Social Security Tax
at
0
1. Print and give to your
0
Medicare Tax
agency payroll office.
TOTAL REFUND
0
Employee Certification
I choose to collect the social security and Medicare tax refund due to me as outlined
above by (choose one):
INSTRUCTIONS TO
PAYROLL OFFICES:
Filing a claim for refund directly with the Internal Revenue Service
1. Collect employee
certification signature.
STOP! If you checked the option above, do not complete the rest of this
2. Retain for your records.
form. You are not eligible for direct payment by your employer.
3. Mark the related
checkbox on the
Receiving a check from the State of Oregon
Request for Corrected
W-2 form.
Complete and sign the certification statement below:
I certify that I choose to receive payment for the over-collected taxes outlined above directly
from my employer. I authorize my employer to claim a refund for the overpayment of my share
of taxes from the Internal Revenue Service. I have not and will not file a claim with the Internal
Revenue Service for recovery of this refund. I declare, under penalties of perjury, that I have
examined the above statements and information and to the best of my knowledge and belief
they are true, correct, and complete.
Date Stamp
Signature:
Date:
Authority
The Internal Revenue Service requires employers to obtain certification from employees
regarding the treatment of over-collected taxes.
Relevant Language:
“…you received written statements from the employees stating that they did not and will not
receive a refund or credit for the prior year taxes.” -- Instructions for Form 941X, Page 4.
Revised 05/2017
Find this information online at:
Form No. OSPS.99.13
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