City Income Tax Return For Individuals (Page 2 of 3) in pdf

Primary

Name(s) as shown on Page 1

Social Security Number

-I

Non-Wage Income

Column O

Column P

Column S

Column Q

Column R

OTHER INCOME FROM FEDERAL

CITY

TOTAL OTHER INCOME (OR LOSS)

INCOME (OR LOSS) FROM FEDERAL

RENTAL INCOME (OR LOSS) FROM

PARTNERSHIP K-1 - ATTACHED

IF GREATER THAN ZERO, CARRY TO PAGE 1,

FEDERAL SCHEDULE E OR

SCHEDULE C AND/OR F - ATTACHED

SCHEDULE Y - ATTACHED

COLUMN C.

Claim for Refund and Adjustments to Taxable Wages

Reason for Adjustment (Explain fully)

Resident Address for this period

Adjustments to Taxable Wages

Part 1

1. If you are claiming employee expenses from Federal Form 2106, enter your total wages from that

job here. Do not include wages included on Lines 14 or 23 below. See instructions.........................

2. Employee business expenses from Federal Form 2106. Do not include 2106 expenses reported on

Lines 15 or 24 below. Attach a copy of the 2106 and Federal Schedule A. See instructions..........

3. Subtract Line 2 from 1. If less than zero, enter zero. List this figure in Part A of Page 1 along with

any other taxable wages you or your spouse earned.................................................................................................................

4. If you were under the age of 18 for all or part of the year, enter your total wages for the year.........

5. Wages earned while under the age of 18. Attach a copy of your birth certificate, a copy of your

driver’s license or a notarized statement from either parent stating your birthday. Enter date of birth

here: _________________________..................................................................................................

6. Subtract Line 5 from 4. List this figure in Part A of Page 1 along with any other taxable wages you

or your spouse earned..................................................................................................................................................................

7. If city tax was improperly withheld from your wages, enter your total wages from that employer ....

8. Income upon which tax was improperly withheld by employer.

Complete Part 2

below................

9. Subtract Line 8 from 7. List this figure in Part A of Page 1 along with any other taxable wages you

or your spouse earned ..................................................................................................................................................................

10. If city tax was improperly withheld from your wages, enter your total wages from that employer ....

11. Income from short-term disability withheld by employer after 7/1/07 ...................................................

12. Income from long-term disability withheld by employer .........................................................................

13. Subtract Lines 11 and 12 from 10. List this figure in Part A of Page 1.

Complete Part 2

below..............................................

14. If you were a nonresident railroad employee or nonresident over-the-road truck driver assigned

duties only within Ohio, enter your total railroad or driving wages here...............................................

15. Enter the amount of 2106 expenses related to this income. Attach a copy of the 2106 & Fed Sch A

16. Subtract Line 15 from 14. If less than zero, enter zero........................................................................

17. Multiply the amount of Line 16 by 10% (.10). List this figure in Part A of Page 1 along with any other

taxable wages you or your spouse earned.

Complete Part 2

below.......................................................................................

If you were a nonresident employee who worked part of the year outside the city for which your employer withheld city tax

complete Lines 18 through 28. Attach a list of the dates and locations worked out. See instructions.

18. Enter the total number of vacation days taken during the entire year...................................................

19. Enter the total number of holidays for the entire year...........................................................................

20. Enter the total number of sick leave days taken during the entire year.................................................

21. Add Lines 18 through 20.......................................................................................................................

22. Subtract line 21 from 260 (total workdays in a year) (see instructions) ..............................................

23. Enter your total wages for this job for the year.....................................................................................

24. Enter the amount of 2106 expenses related to this income. Attach a copy of the 2106 & Fed Sch A

25. Subtract Line 24 from 23. If less than zero, enter zero........................................................................

26. Divide Line 25 by the number of days shown on Line 22.....................................................................

27. Enter the number of days worked in the city (Line 22 less total days worked out)..............................

28. Multiply Line 26 by Line 27. List this figure in Part A of Page 1 along with any other taxable wages

you or your spouse earned.

Complete Part 2

below................................................................................................................

Certification by Employer Regarding Adjustments to Taxable Wages

Part 2

Employer certification is required to claim adjustments on Lines 7 through 28 above. Your request for refund will not be considered valid without a

completed employer certification. A separate certification is required for each job for which you are claiming adjustments on Lines 7 through 28 above.

I/We certify that the employee referenced on this form was employed by the undersigned during the year referenced on this tax return; that the employee was

RESET FORM

either not working inside the corporate limits of the city or city tax was improperly withheld; that no portion of the tax withheld has been or will be refunded

to the employee; and that no adjustment has been or will be made in remitting taxes withheld to the city.

Name of

Employer’s

    

Date

Employer

(

)

Phone No.

Official’s Name Printed

Official’s

    