Us and include "Refund Status" in the subject line or call 216-443-7420 to speak with a Quality Assurance representative. You will receive a refund application form.Proof of payment will be required to process all claims. Need to complete Computation of Overpayment Worksheet. Need to complete Computation of Overpayment Worksheet. 7. We have identified the following overpayment and are in good faith voluntarily refunding all monies collected in error. If you meet the age exemption AND your employer withheld local income tax you may be eligible for a refund. Fill out the Form 10A to apply for a refund. Providers have the option to submit a Request For Extended Repayment Schedule (ERS). A complete ERS request should be submitted immediately.