Reset Form                                    ITAR    
             Depa~ment of                                                                                                                Rev. 7/18
Ohio I Taxation                                                                                                                                       
                                                   111111111111111   II IIIIIII 
                                                             10211411  
Print blank form
           Application for Personal and School District Income Tax Refund  
Important: You may file the Ohio ITAR     only after you have filed an Ohio income tax or school district income tax return 
                                          (Ohio IT 1040, IT 1040EZ or SD 100). 

          For year beginning                        , 20               and ending                                          , 20  

1. Name 
2. Address 
3. SSN                                                          Spouse's SSN  
                                                                (if married filing jointly) 
4. Amount of refund claimed: 
a. By payment of an illegal or erroneous assessment:  
Assessment date                                     Assessment #                                      $  
b. By other payment to Ohio Treasurer of State .........................................................................$  
c. Total amount of refund claimed (prior to calculation of interest) .............................................$  

5. State full and complete reasons for above claim. Include additional sheets, if necessary.  

6. Here's a listing of my income tax payments for the year (include additional payment schedule, if necessary):  

             Type                             Amount                                Type                                         Amount  

Tax withheld                                                    Any additional income tax paid  
Estimated tax paid and overpayment                              Less: Refund(s) previously claimed 
carryforward from previous year                                 (even if not yet received)                                 (                     )  

Tax paid with original return                                   Net Payments                                               $  

Person responsible for the filing of this refund application. I declare under penalty of perjury that I am the taxpayer or 
that I am an authorized agent of the taxpayer and I have knowledge of the relevant facts in the matter to file this 
refund application.  

Signature                                           Date                            Telephone number  

Contact person (if different from the person responsible for filing this refund application).  

Name                                                            Title  

Address                                                         E-mail  

City, state, ZIP code                                           Daytime phone number  

                      Federal Privacy Act Notice                                    File this application in duplicate with:  
Because we require you to provide us with a Social Security number, the Federal     Ohio Department of Taxation  
Privacy Act of 1974 requires us to inform you that providing us with your Social    Attn: Income Tax Division – Ohio ITAR                          
Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057          P.O. Box 2476  
and 5747.08 authorize us to request this information. We need your Social Security  
                                                                                    Columbus, OH 43216-2476  
number in order to administer this tax.