Income Tax Refund Request Form - City Of Springfield, Ohio (Page 2 of 2) in pdf

INSTRUCTIONS

1. THIS FORM IS INTENDED ONLY FOR THE USE OF NON-RESIDENTS, AND MUST BE USED IN CONJUNCTION

WITH A CITY OF SPRINGFIELD INCOME TAX RETURN.

2. Do not combine refund claims for more than one employer. A separate form must be completed for each employer

for which you are claiming a refund of income tax withheld.

3. All claimants must complete Parts A and B and attach copy of applicable W-2 showing Springfield withholding and

Medicare wages.

4. Unless your employer has submitted a list of employees eligible for a refund, you must have an authorized officer or

agent of your employer complete Part C of this form.

5. If you are claiming specific days worked outside this municipality, you must complete the Worksheet below and attach

a log or schedule of dates and places worked outside the City of Springfield.

6. No refunds of ten dollars ( $10.00 ) or less will be issued.

7. Refund claims will not be honored beyond three ( 3 ) years from the date the taxes were due.

8. Please allow ninety ( 90 ) days for processing your completed refund claim.

***PLEASE NOTE: INCOMPLETE CLAIMS CANNOT BE PROCESSED AND WILL BE RETURNED TO CLAIMANT***

The following worksheet is to be completed only by those claiming specific days worked outside the City of

Springfield supported by a log or schedule of dates and places worked.

WORKSHEET

Please note that the average working year consists of 260 available working days, excluding Saturdays and Sundays.

Adjustments may be made to account for various individual work schedules. Training sessions, seminars, meetings,

and temporary or casual employment, although they may be outside the city, do not constitute changes in work situs

and are not factors in determining time worked outside the city.

( A ) TOTAL DAYS AVAILABLE ………………………………………………………………………. ____________

( B ) LESS VACATION DAYS …………………………………………………………………………. ____________

( C ) LESS SICK DAYS ………………………………………………………………………………… ____________

( D ) LESS HOLIDAYS …………………………………………………………………………………. ____________

( E ) LESS OTHER NON-WORKING DAYS ……………………………………………………….… ____________

( F ) TOTAL WORKING DAYS ……………………………………………………….……………….. ____________

( G ) DAYS WORKED OUTSIDE THE CITY OF SPRINGFIELD (ATTACH REQUIRED LOG).. ____________

( H ) DAYS WORKED INSIDE THE CITY OF SPRINGFIELD……………………………………… ____________

COMPUTATION

Compute the amount to be entered as taxable city income by multiplying total income (from box 5 of W-2) by the ratio of

actual days worked in the City of Springfield to total working days:



= $

____________________

( LINE H )

( LINE F )

( TOTAL INCOME )

( TAXABLE CITY INCOME )

INCOME TAX WITHHELD BY EMPLOYER ( FROM W-2 ) ……………………………….. _________________

LESS INCOME TAX DUE ( TAXABLE CITY INCOME x 2.00% ) …………………………. _________________

REFUND CLAIMED ………………………………………………………………….…………. _________________

( to Page 1, Part B )

RefReq (Rev. 1/2017)

Income Tax Refund Request Form - City Of Springfield, Ohio Page 2

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