Form Csuf 5 – Fill Out and Use This PDF

CITY OF PARKERSBURG, WV	Refund Claim Form	Form CSUF - 5
City Service User Fee	Please type or print legibly	(1-2011)

1. Enter Employee Information

Full Name	Employee's Identification Number/Last 4 Digits of Social Security #
Mailing Address (Number and Street)	Phone Number
City, State and Zip Code

2. Enter Claim Information

Employer Name			Employer Identification Number
Amount of Refund
Claimed	$	(Cannot exceed $32.50)

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.

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.