Claim Form For Refund For Withholding Paid To Dublin In Error
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1CLAIM FOR REFUND FOR WITHHOLDING PAID TO DUBLIN IN ERROR
(NON-RESIDENTS ONLY)
City of Dublin Income Tax Division
5200 Emerald Parkway
PO Box 800
Dublin, OH 43017
Telephone: 614.410.4460 | Toll Free: 888.490.8154 | Fax: 614.923.5520
Forms available on internet at
TAX YEAR ___________
This form must cover one (1) calendar year and one (1) employer only.
FORM W-2 MUST BE ATTACHED
1. Name of applicant ______________________ (Phone) _____________ (e-mail) ___________________
2. Present address (Street) ________________________ (City) __________________ (Zip) __________
3. Soc. Sec. No. (SSN) ______________________________ City of employment ____________________
THE UNDERSIGNED HEREBY MAKES CLAIM FOR REFUND OF CITY INCOME TAX
4. In the amount of $ ________________ 5. While in employ of ___________________________________
6. Work location (Street) ____________________________________ (City) _________________________
7. Dates of employment ___________________________________________________________________
8. Resident address (if different than above) for this period ________________________________________
9. Reason for refund request ________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
AND FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER
Date _____________ Signature __________________________________________
CERTIFICATION OF EMPLOYER
I/We herby 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 the corporate limits of the City of Dublin;
no portion of said tax withheld has been or will be refunded to said employee; and no adjustment has been made
in remitting taxes withheld to the City.
_________________________________________ BY: _____________________________________________
(NAME OF EMPLOYER)
Date ____________________________________ TITLE: ___________________________________________
NOTICE:
THIS REFUND MAY RESULT IN A BALANCE DUE TO YOUR RESIDENT CITY AND/OR FEDERAL & STATE TAX RETURN
PLEASE ALLOW 90 DAYS FOR PROCESSING OF YOUR REFUND.
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