APEX USA Inc.
INCOME TAX REFUND
Your profile
Last name ______________________________ Given names ________________________ Social Security Number __ __ __ – __ __ – __ __ __ __
Permanent address
Street ________________________________________________________ Number _____________________ Zip code __ __ __ __ __ __ __ __ City _______________________________________________________ Phone + __________________________ E-mail ______________________@___________________________
Tax information
year Day of arrival to USA (day / month) Day of departure from USA (day / month) Total income from all US sources Federal tax witheld State tax witheld Last tax form used (if any)
2000 2001 2002 2003 2004
Employer profile
Employer (1)
Company name __________________________________________________________________________ Address: Street__________________________________________________________________________ City _____________________________ State __ __ Zip code __ __ __ __ __ I have W-2 - Yes [ ] No [ ] I have my last pay slip - Yes [ ] No [ ]
Employer (2)
Company name __________________________________________________________________________ Address: Street__________________________________________________________________________ City _____________________________ State __ __ Zip code __ __ __ __ __ I have W-2 - Yes [ ] No [ ] I have my last pay slip - Yes [ ] No [ ]
Employer (3)
Company name __________________________________________________________________________ Address: Street__________________________________________________________________________ City _____________________________ State __ __ Zip code __ __ __ __ __ I have W-2 - Yes [ ] No [ ] I have my last pay slip - Yes [ ] No [ ]
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Signature
Either W-2 or last pay slip is necessary for refund. niezbędny jest do rozliczenia i otrzymania zwrotu podatku. If you had more than 3 employers please us the back page. Please include 3 copies of SSCard, visa, paszport and send the letter to:
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Date
Tomasz Tadewicz APEX USA - Tax Dept., Reymonta 27 / 15, 43-100 Tychy Poland