Form Ia-81 - Claim To Support Withholding Tax Credit
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1Division of Taxation
Phone: 785-368-8222
915 SW Harrison St
Fax: 785-296-2073
Topeka, KS 66612-1588
Department of Revenue
Nick Jordan, Secretary
Sam Brownback, Governor
Steve Stotts, Director of Taxations
CLAIM TO SUPPORT WITHHOLDING TAX CREDIT
Customer Relations-Income Tax Unit must have additional information before the amount of
withholding, which you have claimed, can be accepted. Please attach this completed form to a copy of
the letter and mail them to the address above. If you were employed by more than one employer, a
separate form covering each employment and the amount of tax withheld must be submitted.
NAME (First, middle, last)
SOCIAL SECURITY NUMBER
ADDRESS (Number, street, city, state, zip code)
EMPLOYERS NAME
TAX YEAR
FEDERAL
KANSAS
DATES OF EMPLOYMENT
TOTAL WAGES
INCOME TAX
INCOME TAX
WITHHELD
WITHHELD
FROM:
TO:
$
$
$
Month
Year
Month
Year
I do not have copy "B" of my W-2 form, and I am unable to submit the same to the Kansas Department
of Revenue, Division of Taxation. I have not filed any other Kansas Income Tax return for this year
with the original Wage and Tax Statement (Form W-2) nor have I claimed any refund or credit based
upon same, or upon any other W-2 form marked "corrected" or "reissued" by my employer.
Under the penalties of perjury, I declare that the information I have furnished above, to the best of my
knowledge, is true, correct, and complete.
(Signature of Taxpayer)
(Date)
IA-81
(Rev. 5/11)
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