Form 10-A - Application For Municipal Income Tax Refund
ADVERTISEMENT
1APPLICATION FOR MUNICIPAL INCOME TAX REFUND
CITY OF UPPER ARLINGTON
P.O. BOX L-017
COLUMBUS, OHIO 43268-0001
Local (614) 538-0512 – Toll Free 1 (800) 860-7482 – TDD ONLY (440) 526-5332
Taxpayer’s Name
Social Security Number
Address
Municipality of Employment
City, State and Zip Code
Tax Year of Claim
1.
Name of Employer
___________________________________________
2.
Amount of income exempt from tax (check appropriate box below)
$ ___________________
3.
Amount of gross refund claimed
$ ___________________
4.
Amount you want credited to your individual account
$ ___________________
–
–
___________________________
Social Security Number
5.
Net Amount to be refunded (Subtract Line 4 from Line 3)
$ ___________________
CHECK BLOCK BELOW TO INDICATE REASON FOR CLAIM AND ATTACH ALL REQUIRED
DOCUMENTATION (see instructions on the back of this form)
1.
Under 18. ATTACH W-2 AND PROOF OF BIRTHDATE.
2.
Unreimbursed business expenses. ATTACH COPY OF W-2 AND 2106 EXPENSE.
3.
Other ________________________________________________________________________________________
_______________________________________________________________________________________________
EMPLOYER’S CERTIFICATION/COMPUTATION – To be completed by Employer
(See reverse side for instructions)
I/We verify that during 19_____ I/We withheld municipal income tax for the City of UPPER ARLINGTON from the above named
employee in excess of his liability for the tax based on the following computations:
A. From W-2, total wages $______________ on which UPPER ARLINGTON tax withheld was . . . . . . .$ ________________
Worked performed in city of ________________________________subject to tax
UPPER ARLINGTON Taxable Income $________________ x .02 . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
Amount of overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ ________________
B. Basis for refund ______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
C. According to our records, this employee’s address for the period covered by the claim was __________________________
__________________________________________________________________________________________________
I/We verify that no portion of said tax has been or will be refunded directly to the employee and that no adjustments to my/our
withholding account with the City of UPPER ARLINGTON have been or will be made for said tax.
/
/
/
SIGNED ______________________________________________________________________________________________
NAME
TITLE
PHONE #
DATE
/
______________________________________________________________________________________________
PRINT NAME
TITLE
I certify that the facts and allegations contained on this form and on any accompanying schedules are true. I understand that
this information may be released to the tax administration of the city of residence and the I.R.S.
/
/
/
TAXPAYER’S SIGNATURE ________________________________________________________________________________
NAME
PHONE #
DATE
Form 10-A Rev. 12/00
DAYTIME
EVENING
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial