ࡱ> 02/ bjbjT~T~ |66JGGGGG[[[8 [U $M!#GkkkGG kXGGkV@\}[X % 0U x$$\$G\dZ@D4xU kkkk$ :  EMPLOYEE NAME: _______________________________________ SOCIAL SECURITY NUMBER: ______________________________ REFUND AMOUNT: $ ____________ FOR TAX YEAR: ____________ I hereby certify that I am applying for a refund of Social Security and Medicare Taxes in the amount and for the tax period stated above from the University of èapp. In the case of a salary repayment, my net repayment to the University of èapp reflects a reduction of the overpaid FICA taxes. I also certify that I have not previously claimed a refund or credit for the above tax and will not claim one in the future. I am executing this statement under penalties of perjury. __________________________________ Signature _______________________, 20_______ Date ADDRESS TO MAIL REFUND TO: ________________________________ (NO CAMPUS ADDRESSES) ______________________________ ________________________________ NOTE: REFUNDS FOR NONRESIDENTS WILL NEED TWO COPIES OF THE FOLLOWING: 1. VISA 2. I-94 (small white card usually stapled in passport) 3. I-20 for F-1 VISA holders OR IAP-66 and/or DS-2019 for J-1 VISA holders 4. Copy of EAD     REFUND OF EMPLOYEE SOCIAL SECURITY & MEDICARE TAXES **Refunds will be distributed to the employee once the University of èapp has received the funds from the Internal Revenue Service** V > A E H :;JKMNPQSTVŽݹhh5 h5hy Sjhy SUhx( hx( hfMd>*hx( hw>*hwhy+hy+hy+>*hEkhthUhfMd hfMd5\*9pq % &   P Q   [ $a$$a$d$a$ ;JLMOPRSUV$a$gdgdy+gdwz+p ,p -p .p 1h/R 4 5 6 7 :pw/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ hNormalCJ_HaJmH sH tH >> h Heading 1 $@&a$5\DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List 0>@0 hTitlea$5\2B2 h Body Texta$8P8 h Body Text 25\<Q@"< h Body Text 3a$5\4@24 y+Header !4 @B4 y+Footer !PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]   BB  T  # AA@0(  B S  ?zLw"z!z!z<8#zoz 9*urn:schemas-microsoft-com:office:smarttagsplace=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType ` JJLLMMOPRSUVJJLLMMOPRSUVN KRe]O޻+'jD^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.``^``o(.00^0`.L^`L.  ^ `.##^#`.p&Lp&^p&`L.@)@)^@)`.,,^,`..L.^.`L.^`o(.^`.L^`L.^`.X X ^X `.(#L(#^(#`L.%%^%`.((^(`.+L+^+`L.Ne]O+'j         [        p        x( y+08dy9y SfMdEkZwG(th$4UdMJL@`@UnknownG* Times New Roman5Symbol3. * ArialACambria Math"1h+F+F;‰Z Z q0GG2HX ?y+2!xx&REFUND OF EMPLOYEE SOCIAL SECURITY TAX UM AccountingRebecca Bohlmeyer   Oh+'0   <H h t  (REFUND OF EMPLOYEE SOCIAL SECURITY TAXèappAccounting Normal.dotmRebecca Bohlmeyer2Microsoft Office Word@@7>@@Z՜.+,0, hp   University of èapp System G 'REFUND OF EMPLOYEE SOCIAL SECURITY TAX Title  !"#$%&()*+,-.1Root Entry F31Table $WordDocument|SummaryInformation(DocumentSummaryInformation8'CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q