Income Tax Refund Claim Form (Page 2 of 2) in pdf

INSTRUCTIONS

1. THIS FORM IS INTENDED ONLY FOR THE USE OF NON-RESIDENTS AND/OR THOSE UNDER 18 YEARS OF

AGE.

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 claims must be properly signed by the claimant.

4. All claimants must complete Parts A and B and attach copy of W-2 showing Springfield withholding and box 5

Medicare wages.

5. Unless you are under the age of 18, or 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.

6. Refund claims for persons under 18 years of age must include verification of the exact birth date of claimant, i.e.,

photocopy of birth certificate or driver s license.

7. 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.

8. You must file a City of Springfield Income Tax Return in place of, or in addition to, this form if: a) you were a

resident of the City of Springfield for any part of the tax year in question; b) you owned rental property located inside

this municipality and/or you were self-employed and conducted business inside this municipality during the tax year in

question; c) you are a resident of this municipality whose 18

birthday occurred during the tax year in question. For all

of these situations, additional documentation will be required, including but not limited to copies of pay stubs,

verification of move date and/or copies of federal Schedules C and/or E.

9. No refunds of less than one dollar ( $1.00 ) will be issued.

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

11. 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. 1/2013)

Income Tax Refund Claim Form Page 2

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