IT AR  
              Depa~ment of                                                                                                              Rev. 7/18 
           I Taxation 
                                                    111111111111111   II IIIIIII 
                                                              10211411 

           Application for Personal and School District Income Tax Refund 
 Important: You may file the Ohio IT     AR only after you have filed   an Ohio income tax or school district income tax return 
                                           (Ohio IT 1040, IT 1040EZ or SD 100). 

          For year beginning                          , 20             and ending                                           , 20 

1. Name 
2. Address 

3. SSN                                                           Spouse's SSN 
                                                                 (if married filing   jointly) 
4. Amount of refund claimed: 
  a. By payment of an illegal or erroneous assessment: 
  
    Assessment date                                        Assessment #                               $ 
  b. By other payment to Ohio Treasurer of State .........................................................................$ 
  c. Total amount of refund claimed (prior to calculation of interest) .............................................$ 

5. State full and complete reasons for above claim. Include additional sheets, if necessary. 

6. Here's a listing of my income tax payments for the year (include additional payment schedule, if necessary): 

              Type                             Amount                                Type                                        Amount 

 Tax withheld                                                    Any additional income tax paid 
 Estimated tax paid and overpayment                              Less: Refund(s) previously claimed 
 carryforward from previous year                                 (even if not yet received)                                 (                  ) 

 Tax paid with original return                                   Net Payments                                               $ 

Person responsible for the filing of this refund application.  I declare under penalty of perjury that I am the taxpayer or 
that I am an authorized agent of the taxpayer and I have knowledge of the relevant facts in the matter to fi le this 
refund application. 

Signature                                             Date                           Telephone number 

Contact person (if diff erent from the person responsible for filing this refund application).   

Name                                                             Title 

Address                                                          E-mail 

City, state, ZIP code                                            Daytime phone number 

                       Federal Privacy Act Notice                                    File this application in duplicate with: 
 Because we require you to provide us with a Social Security number, the Federal       Ohio Department of Taxation 
 Privacy Act of 1974 requires us to inform you that providing us with your Social      Attn: Income Tax Division – Ohio ITAR                    
 Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057            P.O. Box 2476 
 and 5747.08 authorize us to request this information. We need your Social Security  
                                                                                       Columbus, OH 43216-2476 
 number in order to administer this tax.