CITY OF WAPAKONETA                                   FILE WITH: 
 INCOME TAX DEPARTMENT                                CITY OF WAPAKONETA 
 (419) 738-7342                                       701 PARLETTE COURT 
                                                      P. O. BOX 269 
 REFUND CLAIM              TAX YEAR                   WAPAKONETA, OH  45895-0269 

 NAME                                                                                            

 ADDRESS                                                                                          

 CITY/STATE/ZIP                                                                                   

 SOCIAL SECURITY NUMBER     

 EMPLOYER’S NAME                          WAGES                CITY OF WAPAKONETA 
                                                                 TAX WITHHELD 

 GIVE A BRIEF REASON FOR THE CLAIM: 

 TAX-PAYER CERTIFICATION:                                  MUST ATTACH COPY OF W-2 

 I hereby certify that the statements made herein and the information  provided are true   and 
 correct and that no prior payment has been received from the City of Wapakoneta as a refund 
 for this claim or any portion thereof. 

 Date:      Signature:                       
  
 EMPLOYER CERTIFICATION:                    % IN THE CITY        % OUT OF THE CITY 

 I hereby certify that the statements made herein are true and that the claim for refund by the 
 above named is justified. 

 Date:      Signature:                       

                                        Title:     
  
 FOR TAX DEPARTMENT USE ONLY:                         CITY TAX ACCOUNT #     

 TOTAL WAGES     WAPAKONETA CITY TAX W/H                              

          % TAXABLE =                     TIMES 1.5 % TAX DUE     

 DEDUCT TAXES DUE FROM TAXES WITHHELD – NET REFUND OF