Non-Resident Employee Refund Application
P.O. Box 9062
For Days Worked Out of Dublin
Dublin, OH 43017
(Instructions on reverse side)
Name of Applicant: ___________________________________________________________________________________
Current Address:
___________________________________________________________________________________
City/State/Zip:
___________________________________________________________________________________
Social Security No. ___________________________________________________________________________________
Year: _________________
Salary: _____________________
Tax Withheld: ________________________
Shaded area to be completed by those individuals traveling outside Dublin during year.
Vacation ___________ days: Holidays ___________days: Sick Leave ___________days: Total (1) __________
260 less (1) ___________ = (2) ___________ days worked
Salary $___________________ / (2) ____________________ =(3) average rate per day worked $______________
(2) __________________ less @ _______________ total days worked out of Dublin = (4) ____________ days in Dublin
(4) ____________________ x (3) $___________________= (5) $ ___________________ taxable wages for Dublin
(5) $___________________ x 2% = (6) $ ____________________ Dublin Tax Due
REFUND DUE $ ____________________ . If tax withheld in error, enter total withheld. If refund is due to days worked
out of Dublin, subtract (6) from tax withheld.
Reason: _____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Claimant declares that after examining this for that is to the best of his/her knowledge, true, correct and complete.
Claimant further states that said refund has not been received by him/her.
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 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
NOTICE:
* This refund may result in a balance due to your resident city and/or Federal and
State tax returns.
* Please allow 90 days for processing of your refund request.
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