Report Of Non-Resident Employee Allocation Of Work Form - Massillon Income Tax printable pdf download

MASSILLON INCOME TAX

REPORT OF NON-RESIDENT EMPLOYEE ALLOCATION OF WORK

This form should be used only if you are not a Massillon resident and are requesting a refund

of taxes withheld for working in Massillon when a portion of your wages were earned outside

of Massillon. PROOF OF RESIDENCY IS REQUIRED.

Taxpayer Name:

Social Security # _______________________

Name of Employer:

For Tax Year ____________________

TOTAL HOURS WORKED: __________________________

HOURS WORKED OUTSIDE MASSILLON: __________________________

PERCENTAGE OF TIME WORKED OUTSIDE MASSILLON: __________________________

EMPLOYEE CERTIFICATION

I certify I have examined this filing including all accompanying statements and documents, and declare under penalty of perjury, and

other criminal sanctions, that it is true, correct and that the figures used herein are accurate. I specifically certify that 1.) the hours

noted as representing work outside the City of Massillon was actually for the exclusive business purpose of the employer, 2.) that the

employee was actually compensated by the employer for those hours, 3.) that those hours claimed do not include weekend days, leave

for vacation, personal leave, sick time, compensatory time off, holidays, or any other hours not performing the work or rendering

services of the employer, and 4.) those hours claimed do not include golf outings, meals, conventions, seminars, training and recreation

or entertainment

Taxpayer=s Signature ______________________________________

Date _________________________

EMPLOYER CERTIFICATION

I certify I have examined this filing including all accompanying statements and documents, and declare under penalty of perjury, and

other criminal sanctions, that it is true, correct and that the figures used herein are accurate. I specifically certify that 1.) the hours

noted as representing work outside the City of Massillon was actually for exclusive business purpose of the employer, 2.) that the

employee was actually compensated by the employer for those hours, 3.) that those hours do not include weekend days, leave for

vacation, personal leave, sick time, compensatory time off, holidays, or any other hours not performing the work or rendering services

of the employer, and 4.) those hours claimed do not include golf outings, meals, conventions, seminars, training and recreation or

entertainment. I further specifically certify that I have reviewed documentation that supports the calculation of qualifying hours

worked outside the City of Massillon and that such documentation is retained and available for audit.

______________________________________________________

__________________________________________

Signature of Authorized Payroll Officer of Employer

Date

____________________________________________

____________________________________

Printed Name and Title of Person Signing

Telephone Number

Report Of Non-Resident Employee Allocation Of Work Form - Massillon Income Tax