Occupational Tax Refund Form September 12, 2019 AFFIDAVIT REGARDING PETITION FOR REFUND OF IRONDALE OCCUPATIONAL TAXI, the undersigned, do hereby certify under oath that I am entitled to a refund of City of Irondale Occupational Tax for the period(s) and for the amount(s) indicated below, determined based upon a percentage of time spent working outside of the corporate limits of the City of Irondale, as follows.Full Legal Name* Date* MM slash DD slash YYYY Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Name of Employer* Tax ID #* Work Station Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Title Work PhoneSupervisor or Manager PhonePeriod for which refund is being requested Employee Worksheet1) Total Compensation Subject to Tax*2) .75% of Line 13) Percentage of time worked in Irondale (Documentation Required)*Please enter the percentage in percent format without the percent sign (ie. 100% would be written 100.00)Documentation of time worked in Irondale*Accepted file types: jpg, jpeg, png, tif, pdf, doc, docx, Max. file size: 17 MB.4) Multiply amount of Line #2 by percentage rate on Line #35) Amount of Irondale Occupational Tax withheld (Copy of W-2 form must be attached)*Copy of W-2 form*Accepted file types: jpg, jpeg, png, tif, pdf, doc, docx, Max. file size: 17 MB.6) The difference between Lines #4 and #5, which is additional tax due, or the refund you are claimingI further certify that the information contained herein, to the best of my knowledge, is true and correct.Signature of Employee* Date of Signature* MM slash DD slash YYYY Subscribed and sworn before me this* day of* Notary Public* Statement of EmployerI do hereby certify that I have examined the information above relating to the employee’s job title, job duties, wages, and tax withheld and have determined that this information, to the best of my knowledge, is true and correct. I have also examined the exclusion percentage claimed by the employee and find that it is reasonable, and can be substantiated by the company's books and records.Signature* Date* MM slash DD slash YYYY Name* Title* CAPTCHA
