Non-Resident Employee Refund Application Form For Days Worked Out Of Gahanna - Ohio - Division Of Taxation

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Division of Taxation
CITY OF GAHANNA, OHIO
200 S. Hamilton Rd
Non-Resident Employee Refund Application
Gahanna, OH 43230
For Days Worked Out of Gahanna
Tel 614-342-4030
(Instructions on reverse side)
Fax 614-342-4100
Name of Applicant: _____________________________ Name of Employer: ________________________
Current Address: _________________________________________________________________________
City/State/Zip: ___________________________________________________________________________
Resident Address for Period of Refund Request: _________________________________________________
City/State/Zip: ___________________________________________________________________________
Social Security No.: ________________
City of Employment: _________________
Year: _______
Total Salary: ___________________ Tax Withheld: _______________
;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;
This SECTION to be completed by those individuals traveling outside Gahanna during the year.
Vacation _____________days: Holidays ______________days; Sick Leave _________________days; Total (1) _________________
260 days less (1) ___________ = (2) __________________days worked
Wages $ ___________________ / (2) ____________________ = (3) average rate per day worked $________________________
(2) _____________________less ___________________________ total days worked out of Gahanna = (4) ___________ days in Gahanna
(4) _______________ x (3) $ __________________ = (5) $ _________________________ taxable wages for Gahanna
(5) $________________ x 1 1/2% = (6) $____________________________ Gahanna Tax Due
;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;
REFUND DUE $____________________. If tax withheld in error, enter total withheld. If refund is due to days worked out of Gahanna,
subtract (6) from tax withheld.
Reason: _______________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Claimant declares that to the best of his/her knowledge and belief, this is a true, correct, complete and accurate request for refund.
Claimant further states that said refund has not been received by him/her. Taxpayer also understands this information may be released to the
city of residence, the State of Ohio and the IRS.
Signed: _____________________________________________ Date: ______________________ Phone: _______________________________
CERTIFICATION OF EMPLOYER
I/We hereby certify that the above employee was employed by the undersigned during the period for which said employee makes claim for refund
and that the total amount of $ ______________________ was withheld for the year _______: that said employee was not during the period claimed
above, working inside the corporate limits of the City; that no portion of said tax withheld has been or will be refunded to said employee; and that no
adjustment has been or will be made in remitting taxes withheld to the City.
_______________________________ FID# _________________________ Date: ________________ Phone: _____________________
Name of Employer
______________________________
_______________________________________________________________________________
Name of Authorized Personnel
Signature and Title of Authorized Personnel
PLEASE ALLOW 90 DAYS FOR PROCESSING OF YOUR REFUND REQUEST.

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