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APPLICATION FOR MUNICIPAL INCOME TAX REFUND REGIONAL INCOME TAX AGENCY 10107 Brownsville Road, Brownsville, Ohio 44141 Taxpayers Name Social Security Number Address Municipality of Employment City,
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10107 Brecksville Road Brecksville is a specific address located in Brecksville, Ohio.
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Ohio Brecksville BIRTHDATE Unreimbursed overpayment COMPUTATION Taxable Municipality computations refunded CERTIFICATION certify Subtract credited exempt accompanying EMPLOYERS withheld DOCUMENTATION adjustments Taxpayers MUNICIPAL withholding

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