Employer Request for Employee Reimbursement Form

Use this form when your employee did not live or work in an area with an Earned Income Tax rate and taxes were withheld in error. This form should be filled out by an authorized officer of the employer (business). All information on the form must be filled out to request the money be sent to your employee.

Please note, there is a 3-year statute of limitations on requesting this money be sent to your employee. If multiple years, complete one form for each year.