Form It Ar - Application For Personal Income Tax Refund - 2016
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IT AR
Rev. 9/16
10211411
Application for Personal Income Tax Refund
Type or print in ink.
File this application in duplicate with:
Retain a copy for your records.
Personal income tax refunds are governed by Ohio Revised Code (R.C.)
Ohio Department of Taxation
section 5747.11.
Attn: Income Tax Division – Ohio IT AR
Payment of interest at the rate prescribed by R.C. section 5703.47 is
P.O. Box 2476
issued on all refunds granted.
Columbus, OH 43216-2476
You may fi le the Ohio IT AR only after you have fi led an Ohio income tax or
school district income tax return (Ohio IT 1040, IT 1040EZ or SD 100).
For year beginning
, 20
and ending
, 20
1. Name
2. Address
3. SSN
Spouse's SSN
(if married fi ling jointly)
4. 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) .............................................$
5. State full and complete reasons for above claim. Include additional sheets, if necessary.
6. Here's a listing of my income tax payments for the year (include additional payment schedule, if necessary):
Type
Type
Amount
Amount
Tax withheld
Any additional income tax paid
Estimated tax paid and overpayment
Less: Refund(s) previously claimed
(
)
carryforward from previous year
(even if not yet received)
Tax paid with original return
Net 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 and I have knowledge of the relevant facts in the matter to fi le this
refund application.
Signature
Date
Telephone number
Contact person (if different from the person responsible for fi ling this refund application).
Name
Title
Address
Fax number
City, state, ZIP code
Daytime phone number
E-mail
For state use only
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