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Get PA DoR Wage Tax Refund Petition Salary/Hourly Employees (Formerly 83-A272A) 2020

EMPLOYEE S SIGNATURE Signature must be clear and legible. DATE 83-A272A Rev. 12-18-2017 INSTRUCTIONS FOR FILING WAGE TAX REFUND PETITION Salary and Hourly Employees Only You must attach the applicable W-2 indicating Federal Medicare State and Local wages to the petition. A separate petition must be filed for each W-2 issued by employers that may have overwithheld Wage Tax. TAX YEAR OFFICE USE ONLY WAGE TAX REFUND PETITION SALARY/HOURLY EMPLOYEES Not to be used by Commissioned Employees Read the instructions for both the Employer as well as the Employee on the reverse side of this form prior to completing this petition* Print or type all information* The completed petition must include W-2 showing Federal State Medicare and Local wages Signature of Employee and Employer IRS Form 2106 if claiming expenses on Line 2G* If Form 2106 has an entry on Line 4 submit a breakdown of those expenses. EMPLOYEE S NAME SOCIAL SECURITY NUMBER HOME ADDRESS CITY DAYTIME TELEPHONE NUMBER OCCUPATION STATE ZIP CODE EMPLOYER IF PARTIAL YEAR PROVIDE DATES From To EMPLOYER IDENTIFICATION NUMBER EIN COLUMN A PLACE OF EMPLOYMENT January 1 2017 to June 30 2017 1. Gross Compensation per W-2 July 1 2017 to December 31 2017 A. Non-Taxable Stock Options included in Line 1 Must reflect on W-2 B. Adjusted Gross Compensation Subtract Line 1A from Line 1 2. Computation of taxable compensation and/or allowable expenses A. Number of Days/Hours Include overtime from Line 2C 181 Days/1448 Hours 184 Days/1472 Hours B. Non-workdays/Hours Total of weekend vacation holiday sick or any type of leave time Days/Hours C. Number of actual Workdays/Hours BaseOvertime Line 2A minus Line 2B If computing overtime see instructions on reverse. locations when you worked outside of Philadelphia verified and signed by your employer is required to be attached* Also provide a copy of Telework Agreement if applicable. E* Percentage of time worked outside of Philadelphia* Divide Line 2D by Line 2C. and round the resulting percentage to 4 decimal places. F* Non-taxable compensation earned outside of Philadelphia Line 1B times Line 2E G* i Total non-reimbursed business expenses from Form 2106 and/or Schedule A Miscellaneous Deductions. iii Deductible non-reimbursed employee business expenses. Subtract Line G ii from Line G i H. Non-taxable income and/or deductible employee business expenses Add Line 2F and Line 2G iii 3. Net Taxable compensation Line 1B minus Line 2H Resident of Philadelphia multiply Line 3 Column A by. 039004 and Column B by. 038907. Non-Resident of Philadelphia Line 3 Column A by. 034741 and Column B by. 034654. ii Multiply amount on Line G i by the percentage on Line 2E 4. TAX DUE 5. TOTAL TAX DUE Add Line 4 Column A and Line 4 Column B. 6. Wage tax withheld per W-2 7. REFUND REQUESTED Line 6 minus Line 5 EMPLOYER CERTIFICATION I certify that the facts shown above supporting employee s claims are correct based on available payroll records. Individuals serving as authorized official signatories should be familiar with employee s time and attendance as well as applicable Wage Tax Regulations.

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