Student Refund Request Form - City Of Willard printable pdf download

Student Refund Request Form - City Of Willard

STUDENT REFUND REQUEST FORM

City of Willard

P. O. Box 367

Willard, OH 44890

419 933-7808

I am filing this form as a resident under 18 years of age as of December 31 during calendar

year_________.

Gross wages earned for above year:__________________

Willard tax withheld for above year:_________________

I am attaching a copy of my W-2.

I am attaching a copy of my birth certificate.

MAIL REFUND TO:_________________________________________

_________________________________________

Social Security #:____________________________________________

Date of Birth:_____________________ Age as of December 31:_______________

The undersigned hereby requests under the authority of Article III, E-9, Rules and Regulations, a

refund for overpayment of income tax due to student status. I hereby certify the above

information is true and correct.

__________________________________________

(Signature)

OFFICE USE ONLY

Employer Name:______________________________ Withholding Account #:_____________

Approved by:________

Tax Year:__________

Amount:______________

General Check Requested:__________________

Refund Check#:______________

Refund Check Date:____________________

Student Refund Request Form - City Of Willard