Tax Refund

Document Sample
Tax Refund
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

Day of arrival to Day of departure Total income

Federal tax Last tax form

year USA from USA from all US State tax witheld

witheld used (if any)

(day / month) (day / month) sources

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 [ ]





................................... ............. ...................................

Signature Date

Either W-2 or last pay slip is necessary for refund. niezbędny Tomasz Tadewicz

jest do rozliczenia i otrzymania zwrotu podatku. If you had more

than 3 employers please us the back page. APEX USA - Tax Dept.,

Please include 3 copies of SSCard, visa, paszport and send the

Reymonta 27 / 15,

letter to: 43-100 Tychy

Poland


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