The City of Parkersburg, WV, introduces the CSUF-5 Form as a critical tool for handling refund claims related to the City Service User Fee. Designed to foster a transparent and efficient refund process, this form plays a pivotal role for employees seeking to claim refunds on fees wrongly withheld or in cases of overpayment. Detailing necessary employee information, such as full name, identification numbers, and contact details, the form also demands explicit employer information to facilitate the verification and processing of the claim. A notable requirement is the inclusion of pay stubs to support the claim, underscoring the city's commitment to due diligence. Moreover, the form sets clear deadlines for submission, which hinge upon the timing of the fee's remittance by the employer, thereby establishing a structured timeframe for claimants. Instruction highlights and a declaration section, mandating an affirmation of the provided information's accuracy under penalties of perjury, further illustrate the form’s comprehensive approach to ensuring both parties' responsibilities are clearly communicated and legally bound.
| Question | Answer |
|---|---|
| Form Name | Form Csuf 5 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | stub, remits, withheld, penalties |
CITY OF PARKERSBURG, WV |
Refund Claim Form |
Form CSUF - 5 |
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City Service User Fee |
Please type or print legibly |
1. Enter Employee Information
Full Name |
Employee's Identification Number/Last 4 Digits of Social Security # |
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Mailing Address (Number and Street) |
Phone Number |
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City, State and Zip Code |
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2. Enter Claim Information
Employer Name |
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Employer Identification Number |
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Amount of Refund |
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Claimed |
$ |
(Cannot exceed $32.50) |
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State reason for claiming refund (Attach copies of pay stub(s) reflecting the fee withheld from pay during the period)
I hereby request a refund of the amounts of the fee withheld as specified. I consent to the City of Parkersburg Finance Director verifying this information by contacting the Employer named above. Under penalties of perjury, I declare that the foregoing statement is true, correct and complete to the best of my knowledge.
Employee Signature
Date Signed
Instructions for Refund Claim Form
1.Use this form only if the Employee is claiming a good faith refund of amounts withheld and paid over by the Employer identified. A copy of a pay stub reflecting withholding by the Employer must accompany this form.
2.This form must be filed within 30 days after the fee is paid over to the City of Parkersburg by the Employer that withheld the fee from the Employee. If the Employer remits the fee prior to the due date, then the form must be filed within 30 days after the due date of the remittance.
3.All refund claim forms shall be timely mailed to the City of Parkersburg, Finance Department, PO Box 1627, Parkersburg, WV 26102.