City of Bellefontaine

CITY OF BELLEFONTAINE

NON-RESIDENT CLAIM FOR REFUND

FILE WITH:

DEPARTMENT OF TAXATION

135 N. DETROIT ST.

BELLEFONTAINE, OH 43311

THIS FORM MUST BE FILLED OUT COMPLETELY. ONLY ONE EMPLOYER AND ONE CALENDAR YEAR PER FORM AND YOUR W-2 MUST BE ATTACHED.

NAME OF APPLICANT______

PRESENT ADDRESS______

SOCIAL SECURITY NUMBER______PHONE NUMBER______

THE UNDERSIGNED HEREBY MAKES CLAIM FOR REFUND OF BELLEFONTAINE CITY INCOME TAX:

IN THE AMOUNT OF______

WHILE EMPLOYED BY______

ADDRESS WHERE WORK WAS PERFORMED______

FOR THE PERIOD OF (DATES): FROM______TO:______

HOME ADDRESS FOR THIS PERIOD IF DIFFERENT FROM ABOVE:______

______

REASON FOR CLAIMING A REFUND. EXPLAIN FULLY______

______

TAXPAYER FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED. TAXPAYER ALSO UNDERSTANDS THAT THIS INFORMATION MAY BE RELEASED TO THE TAX ADMINISTRATOR OF THE CITY OF RESIDENCE AND THE INTERNAL REVENUE SERVICE

SIGNATURE______DATE______

CERTIFICATION OF EMPLOYER

I/WE HEREBY CERTIFY THAT THE ABOVE EMPLOYEE WAS EMPLOYED BY THE UNDERSIGNED DURING THE PERIOD STATED ABOVE. I/WE ALSO CERTIFY THAT THE SAID EMPLOYEE WAS NOT WORKING INSIDE THE CORPORATION LIMITS OF BELLEFONTAINE AND THAT NO PORTION OF THE SAID TAX HAS BEEN OR WILL BE REFUNDED TO SAID EMPLOYEE BY US, THE EMPLOYER.

NAME OF EMPLOYER______FID #______

SIGNATURE OF OFFICER______TITLE______

DATE______PHONE______

NOTICE; THIS REFUND MAY RESULT IN AN AMENDMENT TO YOUR FEDERAL, STATE OR OTHER CITY RETURNS. PLEASE ALLOW NINETY (90) DAYS FOR PROCESSING.