Form OSPS.99.13 "Tax Refund Certification" - Oregon

What Is Form OSPS.99.13?

This is a legal form that was released by the Oregon Department of Administrative Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the Oregon Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form OSPS.99.13 by clicking the link below or browse more documents and templates provided by the Oregon Department of Administrative Services.

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Download Form OSPS.99.13 "Tax Refund Certification" - Oregon

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TAX REFUND CERTIFICATION
Use this form to document the employee’s choice for receiving a refund of social security
and Medicare taxes resulting from a Corrected W-2.
Agency No.
Employee SSN
Employee Name
__ __ __ - __ __ - __ __ __ __
OREGON STATEWIDE
Corrected W-2 Detail
PAYROLL SERVICES
(OSPS)
Tax Year Being Corrected
(503) 378-3518 fax
Original Amount
Corrected Amount
Difference
E-mail:
OSPS.Help@oregon.gov
$ 0.00
Social Security Tax
Online Resource Center:
$ 0.00
http://go.usa.gov/bEJk
Medicare Tax
TOTAL REFUND
$ 0.00
INSTRUCTIONS TO
EMPLOYEES:
Complete this form online
Employee Certification
at
http://go.usa.gov/BVNG
I choose to collect the social security and Medicare tax refund due to me as outlined
1. Print and give to your
above by (choose one):
agency payroll office.
 Filing a claim for refund directly with the Internal Revenue Service
INSTRUCTIONS TO
PAYROLL OFFICES:
STOP! If you checked the option above, do not complete the rest of this
1. Collect employee
form. You are not eligible for direct payment by your employer.
certification signature.
2. Retain for your records.
 Receiving a check from the State of Oregon
3. Mark the related
 Complete and sign the certification statement below:
checkbox on the
Request for Corrected
I certify that I choose to receive payment for the over-collected taxes outlined above directly
W-2 form.
from my employer. I have not and will not file a claim with the Internal Revenue Service for
recovery of this refund.
Signature: __________________________________________ Date: _____________
Authority
The Internal Revenue Service requires employers to obtain certification from employees
regarding the treatment of over-collected taxes.
Relevant Language:
“…you received written statements from the employees stating that they did not and will not
For Agency Use
receive a refund or credit for the prior year taxes.” -- Instructions for Form 941X, Page 4.
Received Date Stamp
Find this information online at:
http://www.irs.gov/pub/irs-pdf/i941x.pdf
Revised 2/2016 Form
No. OSPS.99.13
Print
TAX REFUND CERTIFICATION
Use this form to document the employee’s choice for receiving a refund of social security
and Medicare taxes resulting from a Corrected W-2.
Agency No.
Employee SSN
Employee Name
__ __ __ - __ __ - __ __ __ __
OREGON STATEWIDE
Corrected W-2 Detail
PAYROLL SERVICES
(OSPS)
Tax Year Being Corrected
(503) 378-3518 fax
Original Amount
Corrected Amount
Difference
E-mail:
OSPS.Help@oregon.gov
$ 0.00
Social Security Tax
Online Resource Center:
$ 0.00
http://go.usa.gov/bEJk
Medicare Tax
TOTAL REFUND
$ 0.00
INSTRUCTIONS TO
EMPLOYEES:
Complete this form online
Employee Certification
at
http://go.usa.gov/BVNG
I choose to collect the social security and Medicare tax refund due to me as outlined
1. Print and give to your
above by (choose one):
agency payroll office.
 Filing a claim for refund directly with the Internal Revenue Service
INSTRUCTIONS TO
PAYROLL OFFICES:
STOP! If you checked the option above, do not complete the rest of this
1. Collect employee
form. You are not eligible for direct payment by your employer.
certification signature.
2. Retain for your records.
 Receiving a check from the State of Oregon
3. Mark the related
 Complete and sign the certification statement below:
checkbox on the
Request for Corrected
I certify that I choose to receive payment for the over-collected taxes outlined above directly
W-2 form.
from my employer. I have not and will not file a claim with the Internal Revenue Service for
recovery of this refund.
Signature: __________________________________________ Date: _____________
Authority
The Internal Revenue Service requires employers to obtain certification from employees
regarding the treatment of over-collected taxes.
Relevant Language:
“…you received written statements from the employees stating that they did not and will not
For Agency Use
receive a refund or credit for the prior year taxes.” -- Instructions for Form 941X, Page 4.
Received Date Stamp
Find this information online at:
http://www.irs.gov/pub/irs-pdf/i941x.pdf
Revised 2/2016 Form
No. OSPS.99.13