Form W-2 - Claim For Refund Of Tax Withheld For The Time Spent Outside The City

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MUST BE COMPLETED IN EMPLOYEE’S HANDWRITING
W-2 MUST BE ATTACHED
CLAIM FOR REFUND OF TAX WITHHELD FOR THE TIME SPENT OUTSIDE THE
CITY OF ______________AS A NON-RESIDENT
_______ TAX YEAR
During the period __________________, 20___ through ________________ , 20____, I was employed by ___________________
which employer compensated me in the amount of $ _________________ and withheld from such compensation City of
___________________ income tax in the amount of $______________. During this period my legal residence was outside the
City of __________________ as follows:
_____________________________________________
____________________________
__________________
Street
City, Village or Township
State, Zip Code
During the above period I performed work as a _________________________________ on behalf of my employer in areas
outside the City of ________________________ as follows: (Use reverse side or additional pages if necessary.)
CITY & STATE
EXACT DATE(S)
CITY & STATE
EXACT DATE(S)
___________________________
_______________
_________________________
_______________
___________________________
_______________
_________________________
_______________
Weekends spent out of town are NOT to be included as days spent outside the city if the employee’s salary is based on a 40 hr,
Monday – Friday workweek. Vacations, holidays, or sick days are not to be included as days spent outside the city.
Total number of days spent out of town from above ______ = _____________% of time spent out of town
Total number of work days in the year (52 x5)
260
__________________________________________________
_____________________
Signature of Applicant
Date
__________________________________________________
_______________________________________________
Social Security Number
Present Mailing Address
I hereby assign and transfer my right, title and interest in this refund to my city of residence and authorize my city of residence to
accept this refund on my behalf.
Any refund I may be entitled to will be sent to me by my city of residence.
____________________________________
Signature of Applicant
TO:
COMMISSIONER OF TAXATION
CITY OF ____________________, OHIO
STATEMENT OF EMPLOYER
Under penalties of perjury, the undersigned employer states that the above employee was employed by him during the period
__________________, 20___ through ____________________, 20___, that $ _______________ was withheld as City of
______________________ income tax from earnings paid said employee during that period; that he has examined this claim for
refund of $ __________________ including accompanying schedules and statements and that to the best of his knowledge and
belief this refund claim is true and correct; that the earnings claimed above were earned outside the corporate limits of the City of
_________________ and that no portion of said tax has been or will be refunded to said employee by this employer.
___________________________________________________
CERTIFIED BY: _______________________________
Name of Employer
Signature of Authorized Representative
Prepared By: ________________________________________
________________________________
Print or Type Applicant’s Name

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