City of Westerville, Income Tax Division 
                          PO BOX 130 
                          WESTERVILLE, OH   43086-0130 
                 WWW.WESTERVILLE.ORG/incometax  
                  (Tel No. 614/901-6420 - Fax No. 614/901-6820) 

                 TAX REFUND REQUEST FOR UNDER 18 

                          TAX  YEAR ________ 

Please Print 

NAME:  ________________________     SOCIAL SECURITY:   ___________________________ 

PRESENT ADDRESS:          ___________________________________________________ 

CITY, STATE AND ZIP CODE: ___________________________________________________ 

TELEPHONE NO. _____________________ 

TOTAL  WESTERVILLE TAX WITHELD  $ ___________ 

REFUND AMOUNT REQUESTED $__________________ - Request must be greater than $10.00 

COMPANY’S NAME:  ____________________________________________________ 

ADDRESS WHERE WORKED:     ______________________________________________ 

PROOF OF BIRTH MUST ACCOMPANY THIS REQUEST FOR A REFUND.  PROOF SHOULD BE 
A LEGIBLE COPY OF BIRTH CERTIFICATE OR DRIVER’S LICENSE. 

W-2 FORM MUST BE ATTACHED.

SIGNATURE: __________________________ DATE: __________________ 

NOTICE:

PLEASE ALLOW 90 DAYS FOR PROCESSING OF YOU REFUND  REQUEST

(REV. 12/12/ )81