places traveled for business, indicating the number of business days out ____/260 days. See instructions.
Unreimbursed Employee Expenses. See instructions. Other (explain)_________________________________________________________________________________ ____________________________________________________________________________________________________ Computation of Overpayment 1. Wages reported on W-2 form (attach W-2s) 1._________________________ 2. Less Wages Not Subject to Tax 2._________________________ 3. Net Taxable Wages 3._________________________ 4. Corrected Tax 4._________________________ 5. Tax Withheld 5._______________ 6. Prior Year Credit 6._______________ 7. Estimate Paid 7._______________ 8. Total Credits 8._______________ 9. Refund Requested 9.__________________________ I DECLARE UNDER THE PENALITIES OF PERJURY THAT THIS CLAIM (INCLUDING ANY ACCOMPANYING STATEMENTS) HAS BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS TRUE AND CORRECT. I AUTHORIZE THE DISCLOSURE OF THE INFORMATION HEREIN TO ANY LAWFUL TAXING AUTHORITY AFFECTED BY THE REFUND.Taxpayer’s Signature:_______________________________________________ Date:___________________________
Spouse’s Signature:_________________________________________________ Date:___________________________
Preparer’s Signature:________________________________________________ Date:___________________________
EMPLOYERS CERTIFICATION ( TO BE COMPLETED BY EMPLOYER) We have reviewed the above calculations and attachments and believe them to be true and correct.I/we verify that no portion of said tax has been or will be refunded directly to the employee and that no adjustment to my/our withholding
account with the City of _____________________________ have been or will be made for said tax.Employer’s Signature:_______________________________________ Title___________________________ Date:_________________
Company:________________________________________________ FEID___________________________ Phone:________________