Income Tax Refund Claim Form - City Of Huber Heights Page 2
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1
2INSTRUCTIONS
1. Complete the top portion of form with current information.
2. If you are claiming a refund for a portion of days out of the city, complete the worksheet below and attach
a list of cities and dates worked out of the City of Huber Heights.
3. If you are claiming a refund for a percentage of hours worked out of the city, indicate that percentage on
the front of the form and have employer sign and certify such information.
4. If you are claiming a refund because you were under 18 years of age, please include verification of your
date of birth (attach a copy of your birth certificate). (Age 16 prior to 01/01/2009)
5. Complete the Income and Tax Distribution worksheet.
6. Attach W-2’s.
7. All refund claim forms must be signed by taxpayer.
8. The Employer Certification must be signed below.
9. No refunds will be made for amounts less than ten dollars ($10.00).
10. Refund requests will not be honored beyond three (3) years from the date the taxes were due.
Please allow ninety (90) days for processing your refund request.
Incomplete claims cannot be approved and will be returned to claimant.
WORKSHEET
Note: The average working year consists of 260 days (Saturdays and Sundays are not considered working days.)
Training sessions, seminars, meetings, 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 out of the city.
1) Total Days Available………………………………………………………………..____260_______
a) Vacation Days Used……………______________
b) Sick Days Used………………...______________
c) Holidays Used………………….______________
0
2) Less Total Days Not Worked (a+b+c)…………………………………………...……_____________
260
3) Total Working Days (Line 1 minus Line 2)……………………………………………_____________
4) Less Days Worked Out of the City of Huber Heights (Attach Log)…...……………. _____________
260
5) Days On Job In the City of Huber Heights (Line 3 minus Line 4)……………………_____________
CALCULATION
260
260
Line 5__________ divided by Line 3__________ x Total Income $________________= $_______________
(Taxable City Income)
Net Tax Due (Taxable City income x tax rate (see page 1)……………………………..….$_______________
Less Income Tax Withheld ………………………………………………………………....$_______________
0.00
Refund Claimed (Tax Due Minus Tax Withheld)……………………………………...….....$_______________
EMPLOYER CERTIFICATION
.)
(To be completed by employer
The employee named on the reverse side of this form has claimed a refund for the reasons listed. As any refund to
one of your employees will result in a debit from your withholding tax account, we require verification of this
claim.
I/We hereby certify that _______________________ (employee) was employed by the undersigned during the
0.00
period covered by this claim, and that the City of Huber Heights income tax in the amount of $__________was
withheld in excess of his/her liability based on the above stated facts and calculations. No portion of these taxes
has been or will be refunded to the employee and no adjustment to our withholding remittance has been or will be
.
made
Employer Name________________________________________ FID #________________________
Signature & Title_______________________________ Date ___________Phone #_______________
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