Form Nrr - Claim From Non-Resident Of Toledo For Tax Withheld By Employer On Wages Earned Outside Toledo
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1Do not use highlighter on this form or its attachments
*W-2 MUST BE ATTACHED*
TAX YEAR
FORM NRR REV 3-2014
________________
CLAIM FROM NON-RESIDENT OF TOLEDO
FOR TAX WITHHELD BY EMPLOYER ON WAGES EARNED OUTSIDE TOLEDO
During the period _____________, _______ thru ______________, _______, I was employed by ______________________
which employer compensated me in the amount of $ _____________ and withheld from such compensation Toledo Income
Tax in the amount of $ ____________. During this period my legal residence was outside the City of Toledo as follows:
____________________________________________________________________________________________________
Street
City, Village or Township
State
Zip
During the above period, I performed work as a ________________________ on behalf of my employer in the areas outside the
City of Toledo as follows: (Use an attached sheet if necessary).
*THIS SECTION MUST BE COMPLETED IN DETAIL*
TWP/VILLAGE
BUSINESS
TWP/VILLAGE
BUSINESS
EXACT DATE(S)
CITY/STATE
PURPOSE
EXACT DATE(S)
CITY/STATE
PURPOSE
________________________________________________________
_______________________________________________________
________________________________________________________
_______________________________________________________
________________________________________________________
_______________________________________________________
Weekend days are NOT included as days worked outside Toledo if the employee’s salary is based on a 40 hour Monday-Friday workweek.
Days spent “working at home” are NOT included as days outside Toledo unless you have a separate letter from your employer stating that the
employer does not provide you an office, and that you work at home for the convenience of your employer. If you spent 12 or more days in an
Vacations, holidays, and sick days are not to be included as days
Ohio City, attach a copy of tax return filed with that city.
worked outside Toledo.
Total No. of days worked outside Toledo from above ___________ = ____________ = % of time worked outside of Toledo.
Total No. of work days in the year (52 X 5)
260
_____________________________________________
________________________________(_____)_______________
Signature of Employee
Date
Printed Name of Employee
Phone Number
_____________________________________________
_____________________________________________________
Social Security Number
Present mailing address if different
I hereby assign and transfer my rights, title and interest in this refund to my city of residence and authorize my city of residence to
accept this refund on my behalf.
*SIGN THIS BOX ONLY TO TRANSFER YOUR
REFUND TO YOUR CITY OF RESIDENCE
___________________________________________
SIGNATURE AUTHORIZING TRANSFER
STATEMENT OF EMPLOYER (Required)
TO: Commissioner of Taxation and Treasury
One Government Center, #2070
Toledo, OH 43604-2280 Attention: Refund
Under penalties of perjury, the undersigned employer representative states that the above employee was employed during the period
_________, _______, thru __________, ______, that $ __________ was withheld as Toledo Income Tax from earnings paid said employee
during that period; that the employer representative has examined this claim for refund of $ ____________ including accompanying
schedules and statements and can attest that the information contained hereon is true and accurate; that the earnings claimed above
were earned outside the corporate limits of the City of Toledo and that no portion of said tax has been or will be refunded to said employee
by this employer.
______________________CERTIFIED BY: _____________________________________________________///_______________________
Name of Employer
Signature
Title
Date
Phone # of Certifying Agent
PREPARED BY: _____________________________________________///_____________________________________________________
Print or Type Preparer’s Name
Print or Type Name of Certifying Agent
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