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