Form IA-81 Claim to Support Withholding Tax Credit

(Signature of Taxpayer) (Date) Month SOCIAL SECURITY NUMBER TAX YEAR (Rev 5/11) 915 SW Harrison St Fax: 785 296 2073 ADDRESS (Number street city state zip code) CLAIM TO SUPPORT WITHHOLDING TAX CREDIT Customer Relations Income Tax Unit must have additional information before the amount of withholding which you have claimed can be accepted Please attach this completed form to a copy of the letter and mail them in the enclosed envelope If you were employed by more than one employer a separate form covering each employment and the amount of tax withheld must be submitted DATES OF EMPLOYMENT Division of Taxation Phone: 785 368 8222 EMPLOYERS NAME FEDERAL I do not have copy "B" of my W 2 form and I am unable to submit the same to the Kansas Department of Revenue Division of Taxation I have not filed any other Kansas Income Tax return for this year with the original Wage and Tax Statement (Form W 2) nor have I claimed any refund or credit based upon same or upon any other W 2 form marked "corrected" or "reissued" by my employer IA 81 INCOME TAX WITHHELD KANSAS NAME (First middle last) Nick Jordan Secretary Department of Revenue Sam Brownback Governor Steve Stotts Director of Taxations Topeka KS 66625 2007 ksrevenue org TOTAL WAGES Under the penalties of perjury I declare that the information I have furnished above to the best of my knowledge is true correct and complete