OFFICE  USE                                                                                                SELECT  JEDD 
                                                           APPLICATION 
                                                                                                           BATH-AKRON-FAIRLAWN
 FOR  TAX                                                 FOR   REFUND                                     COPLEY-AKRON
 YEAR                                                                                                      COVENTRY-AKRON
                                                   JEDD  INCOME   TAX                                      SPRINGFIELD-AKRON

 _________                                                UNDER 18 FILERS                                  330-375-2039

Print  Name  &  Address  Below:                                            Telephone Number 

                                                                           Work ____________________________

                                                                           Home ___________________________ 

                                                                           SS#_________________________ _____

1. Enter total compensation received before any payroll deductions (attach copies of W-2’s) ………….  $ ___________________
       Print  Employer  Name               Dept Name or #                City Where Employed                    Work Location  (Address) 

 You must submit the following in order for you refund to be processed.

        1. Legible copy of birth certificate or driver's license.

        2. Copy of W-2(s) showing JEDD wages and JEDD tax withheld.

 We will calculate and issue a refund based on the information provided. 
 Refunds are typically issued within 90 days after: i) the date the City has received a complete and accurate 
 Refund Application, plus a copy of your employer’s complete and accurate JW-3 reconciliation form; or ii) April 
 15th of the year following the tax year at issue, whichever is later.
                                                                        . 

        If you were not assigned to the above employer’s JEDD payroll for the entire year,  report the date you were assigned 
        to the JEDD payroll and/or the date you were transferred out, and/or the date employment was terminated. 

 (I worked in the JEDD  from  _________________________  to  _________________________) 

 I certify that I have examined this refund application, including any accompanying documents, and to the best of my 
 knowledge and belief I attest that these documents represent a true and complete record of my taxable income to the JEDD. 

_______________________________________________                              _______________________________________ 
 Signature of Taxpayer                                                                                 Date

   Return completed form to :  JEDD INCOME TAX, 
                                                 1 Cascade Plaza  Suite 100
                                                                                                                                         2/2022 
                                                 Akron, OH  44308 3