The Oklahoma WC-12 form is a request for a rebate from the Workers’ Compensation Multiple Injury Trust Fund, designed for employers or insurance carriers that have made multiple injury trust fund payments. This form allows eligible parties to apply for rebates on assessments paid in the previous calendar year, with specific deadlines and requirements outlined by the Oklahoma Tax Commission. Understanding the nuances of this form is essential for ensuring compliance and maximizing potential rebates.
The Oklahoma WC-12 form serves a critical role in the state’s workers' compensation system, specifically regarding the Multiple Injury Trust Fund. This form is essential for employers and insurance carriers seeking a rebate for contributions made to the fund. It requires the submission of specific details, including the name of the employer or insurance carrier, their federal identification number, and banking information for the rebate deposit. The form also mandates that applicants report the total payments made to the Multiple Injury Trust Fund and calculate the rebate requested, which is two-thirds of that total amount. Furthermore, individuals must certify the accuracy of the information provided, affirming their authority to submit the request on behalf of the employer or carrier. It is important to note that the Oklahoma Tax Commission only accepts rebate applications for the previous calendar year, with a deadline of May 31 for submission. Failure to meet this deadline results in a 10% reduction in the rebate amount. Rebate payments are typically processed after July 1 each year, making timely submission essential for eligible parties.
Form WC-12
Revised 1-2014
WORKERS’ COMPENSATION
MULTIPLE INJURY TRUST FUND REBATE REQUEST
FOR TAX YEAR
Name of Own Risk Employer or Insurance Carrier:
Federal Employer’s Identiication Number:
Street Address:
City, State and Zip Code:
Bank Routing Number:
Bank Account Number:
Checking
Savings
1. Total Multiple Injury Trust Fund Payments:
2. Rebate Requested (2/3 of Amount Entered on Line 1.):
The undersigned hereby certiies, under penalty of perjury, that he/she has executed this rebate request of
his/her free and voluntary will and as the duly authorized representative of the own risk employer/carrier named above and that the information and amounts herein contained relect a true, accurate, and complete statement.
Signed (name of own risk employer/carrier)
Date:
By (signature)
Printed Name and Title:
Telephone Number:
Beginning January 1, 2003, the Oklahoma Tax Commission shall accept applications for rebates from all eligible parties for assessments paid pertaining to the previous calendar year. Beginning with the calendar year of 2007, if any party fails to apply for a rebate on or before May 31 of each year, the Tax Commission shall reduce the amount of the rebate in the application by ten percent (10%). No rebates shall be paid until after July 1 of each year.
MAIL TO: OKLAHOMA TAX COMMISSION
ACCOUNT MAINTENANCE DIVISION
2501 NORTH LINCOLN BLVD.
OKLAHOMA CITY, OK 73194
OFFICE USE ONLY
Veriied Rebate Amount: $ __________________________________
Supervisor Initials: _________________________________
Reviewed by: ____________________________________________
Approved by: _____________________________________
Account Maintenance Division
Difference in rounding
Used .666 instead of 2/3
Used .667 instead of 2/3
Used .6666 instead of 2/3
Used .6667 instead of 2/3
Used ________ instead of 2/3
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