City of Pickerington                                                                                                           To be used only by individuals under 18 or by  
Income Tax Department                                                non-residents who have had Pickerington 
100 Lockville Road                                                                taxes withheld erroneously 
 Pickerington, Ohio 43147                                                
                                CLAIM FOR REFUND 
                                                   
This form can cover one calendar year and one employer only.  A copy of form W-2 showing Pickerington City 
tax withheld must be attached.  Additionally, if claimant is under 18, a copy of birth certificate or driver’s license 
must be attached. 
 
NAME OF APPLICANT:
   LAST NAME                                       FIRST NAME                             MIDDLE
 
PRESENT ADDRESS:
 
SOCIAL SECURITY NO.:           
 
CITY OF EMPLOYMENT:           
 
REFUND IN THE AMOUNT OF $          
 
WHILE IN THE EMPLOY OF:           
 
FOR THE DATES FROM:      TO:      
 
RESIDENT ADDRESS FOR THESE DATES:
 
REASON (EXPLAIN FULLY OR ATTACH WORK SCHEDULE/LOCATIONS):
             
CLAIMANT FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER.  TAXPAYER 
ALSO UNDERSTANDS THIS INFORMATION MAY BE RELEASED TO THE TAX ADMINISTRATION OF THE 
CITY OF RESIDENCE AND/OR THE IRS. 
 
SIGNATURE:             
 
DATE:      PHONE NUMBER:       
 
                                CERTIFICATION OF EMPLOYER 
I/We hereby certify that the above employee was employed by the undersigned during the period during which 
said employee makes claim for refund and that the total amount of $                was withheld for the 
year 20            ; that no portion of said tax withheld has been or will be refunded to said employee; and that no 
adjustment has been made or will be made in remitting taxes withheld to the City. 
 
NAME OF EMPLOYER                                   SIGNATURE OF OFFICER
 
DATE:                     FID#:   TITLE:                                          PHONE:
 
NOTICE:             
     No refund will be issued for amounts less than $10.01 
     This refund may result in an amendment to Federal, State, or other city tax returns 
     Refunds over $10.00 are reported to the IRS 
     Please allow up to 90 days for processing of your refund request