CITY OF LAKEWOOD - Division of Municipal Income Tax                           FORM L-REV
              12805 Detroit Ave., Suite 1     Lakewood, Oh 44107
              Phone:  (216) 529-6620     Fax:  (216) 529-6099                               Tax Year_______
              www.onelakewood.com

                                                APPLICATION FOR REFUND
                                                               Check here if you worked outside of your normal place of 
Check Status:          Individual         Joint                work in 2020 due to COVID-19.  Please see option E below.
Your Social Security Number Spouse's Social Security Number      IF MOVED DURING YEAR- 
____________________        _______________________
                                                               Enter date moved: ____/_____/____
Your first name and initial                     Last Name
_____________________________________________                  Enter former address:
If a joint return, spouse's first name and initial Last Name   Address                      Apt. No.
_____________________________________________                  ___________________________________________
Address                                         Apt. No.       City, State and Zip Code
_____________________________________________                  ___________________________________________
City, State and Zip Code
_____________________________________________

        PLEASE CHECK BLOCK BELOW THE TYPE OF CLAIM FILED (SEE INSTRUCTIONS)
   A. Refund because the employer continued to withhold Lakewood residence income tax after the taxpayer moved out of Lakewood
   B. Refund because the employer withheld more than 1% for Lakewood residence income tax
   C. Refund of Lakewood employment tax withheld on wages earned outside of Lakewood (business days out _____/260 days). 
   D. Refund because the taxpayer was under 18 years of age for all or part of the tax year (disregard Employer Certification)
   E. Due to COVID-19, days worked outside of Lakewood for which the employer withheld tax.  See Instructions.
   F. Other: __________________________________________________________________________________________________
        Computation of Overpayment (see instructions)
1.      Wages as reported on W-2 Form (Attach W-2)……………………………………………1.  $_________________________
2.      Lakewood Tax Withheld as reported on W2………………………………………………..2.  $_________________________
3.      Lakewood Income Tax due…………………………………………………………………………………………………3.  $_________________________
4.      Amount of overpayment…..………………………………………………………4.  $_________________________
5.      Minus the  amount you would like credited to your account…………  5.  $_________________________
6.      Net amount to be refunded (no refund if $10.00 or less)…………..  6.  $_________________________

I DECLARE UNDER THE PENALTIES 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_______________Telephone Number____________
Spouse's Signature_____________________________ Date_______________
Preparer's Signature_____________________________Date______________Telephone Number_____________

              EMPLOYER'S CERTIFICATION (To be completed by employer)
I/We declare under the penalties of perjury that I/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 adjustments to my/our withholding account with the City of Lakewood have been or will be made 
for said tax. 

Employer's Signature____________________________Title________________________Date_____________

Company___________________________Federal ID #_________________Telephone (      )_____________

                                        INSTRUCTIONS FOR FORM L-REV
        Who May Use This Form:  Persons seeking a refund of municipal tax paid to or withheld for the City of Lakewood. 
                   NOTE:  If the amount of the overpayment is $10.00 or less the amount will not be refunded.
Year of return:                 Enter the year that this claim covers in the upper right corner of this form.  A separate
                                L-REV Form is required for each year filed.
                                NOTE:  The Statute of Limitations for refunds is three (3) years.
Social Security Number:         Enter your social security number.  If you are filing jointly, include your spouse's social
                                security number.
Name and Address:               Enter your name and address in the space provided.  If you moved during the year, indicate
                                the date moved and show you former address.
Type of Claim Filed:  Check the box for the type of refund claim you are filing.
A.      The employer continued to withhold Lakewood residence income tax after your move out of Lakewood.
B.      The employer withheld more than 1% for Lakewood residence income tax.
C.      Days out of the City of Lakewood must be documented with a travel log showing the date, place, and business 
        purpose of travel. The following formula is used to arrive at the percentage of income to be excluded from tax:
            Days Worked Out of the City
                                         x Local Wages = Amount Excluded
                Total Working Days (260)
        Saturdays, Sundays, sick days, vacation days and holidays are not to be counted as days worked out of the city.
        Total working days should be 260, unless you worked a partial year. On the income earned while traveling, you
        will owe residence tax to your home city at the full percentage rate.
D.      Tax was withheld on income earned while under eighteen (18) years old. Please attach copy of W-2, legible
        photocopy of your driver's license, State ID or birth certificate with the birth date clearly readable. If you reached
        the minimum age of eighteen (18) years old during the taxable year, you may be entitled to a refund of any 
        Lakewood tax withheld prior to your birthdate. 
        NOTE: The Employer Certification section may be ignored in this case.
E.      The availability of a refund is dependent upon the outcome of pending litigation. Requests will be held until this
        litigation is resolved. Attach a copy of your W-2, a log of days out, and a calculation for days worked out. Your
        employer must complete and sign the Employer's Certification at the bottom of page 1.
F.      Explain reason for refund on line provided and attach any applicable supporting documentation.
Computation of overpayment:
Line 1: Enter the amount of local wages that your employer showed on your W-2 Form.  Wages that are deferred for Federal
        and State purposes must be included in Local Wages.  All W-2 Forms, 1099s, and statements showing 
        reimbursements must be attached.  If more than one employer, use a separate L-REV Form for each employer.
Line 2: Indicate the amount of tax withheld by your employer.
Line 3: Enter the amount of Lakewood Income Tax due from your previously calculated tax return, taking into account any
        amount to be excluded in the case of a days out scenario.
Line 4: Subtract line 4 from line 3.  This is the amount of your overpayment.
Line 5: Indicate the amount you would like credited to your account.
Line 6: Subtract line 5 from line 4.  This is the amount to be refunded.
Sign Your Application           Your application for refund is not complete if it is not signed.  On a joint application, both
For Refund:                     spouses must sign.  If you are filing this form on behalf of another person, a Power of
                                Attorney form must accompany this form. 
Employer's Certification:       The Employer's Certification must be signed by the employee's supervisor or other
                                responsible representative of the employer who has knowledge that the information given
                                is true and correct.  The only exception is in the case of refunds for tax withheld while
                                under eighteen (18) years old.
Penalties for Filing a          Persons filing a fraudulent return shall be guilty of a misdemeanor and shall be fined not
Fraudulent Return:              more than Five Hundred Dollars ($500.00) imprisoned not more the six (6) months or both,
                                for each offense.