CITY OF OAKWOOD INCOME TAX

REFUND REQUEST FORM

PART I

Check at least one: Non-Resident Under Age 18

A. NAME AND CURRENT ADDRESS

For the Calendar Year

Refund Claimed $

Social Security No.

Address during claim period:

Employer's Name and Address:

B. COMPUTATION OF OVERPAYMENT:

1. Income Earned (Typically Box 5 of form W-2)

2. Oakwood Tax Withheld (attach copy of form W2)

3. Earnings Subject to Oakwood Tax

4. Oakwood Tax (2.5% of line 3)

5. Overpayment Claimed (line 2 minus line 4)

Please note that in accordance with Ohio Revised Code Section 718.19, refunds requested of $10.00 or less cannot be issued.

C. BASIS FOR REFUND: Give brief but complete explanation. If applicable, complete days out computation on page 2.

The City of Oakwood will furnish your city of residence and any employment city a copy of this refund document.

The undersigned declares that all information given is true and complete to the best of his/her knowledge and belief, that a refund has not previously been claimed or received by him/her for the period covered by this claim.

SIGNED:

(Claimant's Signature)

DATE:

PART II - EMPLOYER'S CERTIFICATION (Read Carefully) – Not required for persons under age 18

During 20 , City of Oakwood Income Tax in the amount of $ was withheld from the above-named employee's wages in excess of his/her liability based on the above stated facts and the computation shown on the reverse side of this form.

No portion of said taxes has been or will be refunded directly to the employee and no adjustment to our withholding account with the City of Oakwood has been or will be made for said tax.

EMPLOYER NAME:

FEI #:

AUTHORIZED SIGNATURE:

DATE:

PRINTED NAME:

TITLE: