OFFICE  USE                                                                                        SELECT  JEDD 
                                                          APPLICATION 
                                                                                                   BATH-AKRON-FAIRLAWN
 FOR  TAX                                                 FOR   REFUND                             COPLEY-AKRON
 YEAR                                                                                              COVENTRY-AKRON
                                 JEDD  INCOME   TAX                                                SPRINGFIELD-AKRON
 _________                       (2106 Expense  or  Underage filers) 

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) 

   2.    2106  EXPENSES  -  Attach Federal Form 1040 (pages 1 & 2), Schedule 1, Form 2106 and copies of all W-2s.  

   3.    UNDER  18 YEARS OF AGE  for the entire tax year … attach a copy of your driver’s license or 
     birth certificate  (BIRTH DATE MUST BE CLEARLY READABLE) 

 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 AW-3 reconciliation form; or ii) 
 April 15th of the year following the tax year at issue, whichever is later.
 YOU MUST ATTACH COPIES OF W-2’S SHOWING JEDD WAGES AND JEDD INCOME TAXES WITHHELD. 

   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,  PO Box 80538,  Akron, OH  44308 
                                                          (330) 375-2539                                                         2/2021