Form E-1r - Individual Earnings Tax Refund Request November - 2016 Page 2
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1
2IMPORTANT INFORMATION
• This form is to be used by non-residents requesting a refund based on days worked outside the City of St. Louis. Stock options not represented on the W-2
will require documentation from your employer.
• Please use Form E-1 if you owe the City of St. Louis Earnings Tax.
• Annual leave, sick leave, and/or separation pay of any person who is terminated or separated from a place of employment located within the City of St.
Louis is taxable in the year received. No exceptions will be allowed on the basis of where it is earned or where the taxpayer resides.
• Non-residency deduction claims must be supported by a copy of a mortgage deed or lease to verify the time lived in the City of St. Louis.
• There is a one year statute of limitations on refund claims. Form 1099-G will be issued to all taxpayers receiving a refund.
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• Form E-1R must be filed on or before April 15
. Joint returns will not be permitted. Please mail all returns to:
Gregory F.X. Daly
Collector of Revenue
1200 Market Street, Room 410
St. Louis, MO 63103-2841
INSTRUCTIONS
1.
On lines A, B, C & D please enter the total gross wages from box 1 of each W-2, excluding any income derived from stock options.
2.
In box 2, please enter the total of lines A thru D.
3.
Please complete the non-residency formula found below.
4.
In box 4, subtract line 3 from line 2.
5.
In box 5, please enter 1% of line 4.
6.
In box 6, enter the total amount of Earnings Tax withheld from each W-2.
7.
In box 7, subtract line 5 from line 6.
EMPLOYEE VERIFICATION SECTION
(TO BE COMPLETED BY EACH EMPLOYER)
In order to claim a non-residency deduction, the following must be completed by the appropriate personnel. Non-resident taxpayers seeking a
“Non-Residency Deduction” must only claim whole days worked outside the City. Employees who start and/or finish their work day in the City are not
allowed to use that as a day worked out of the City per Streckfus Steamers vs. City of St. Louis 472 S.W. 2d 660 (1971). Please note: neither vacation and
sick days nor holidays are allowed as a deduction.
This is to certify the below mentioned employee, a non-resident of the City of St. Louis, worked a total of
days including vacation,
sick, and holidays everywhere.
This is to certify the below mentioned employee, a non-resident of the City of St. Louis, worked outside the City of St. Louis a total
of
whole days.
Address of work location must be provided for days worked outside the City of St. Louis. Please provide address on the line below.
The standard work year is 260 days. If the employee worked more or less than 260 days or moved in or out of the City of St. Louis during the year,
an explanation must be provided on the line below (attach separate sheet if additional space is needed).
I certify, to the best of my knowledge, that the above information is true and accurate, and the records are available to verify this information.
Please complete the following information.
THE AREA BELOW FOR POST OFFICE USE ONLY
Employee Name:
The “Official Post Office Branch Date Stamp” must be
Company Name:
placed below for Postal Employees requesting a refund.
Company Address:
Company Phone Number:
Printed Name of Supervisor/Manager:
Signature:
Title:
Date:
NON-RESIDENCY DEDUCTION FORMULA
Please complete and enter the result on line 3 of the reverse side.
1. Total work days (standard work year is 260 days)
_______________ days
2. Days lived or worked outside the City (include documentation)
_______________ days
3. Percentage of days lived or worked outside the City (line 2 ÷ line 1)
_______________ %
4. Gross wages reported on W-2
$ _______________
5. Non-residency deduction (line 4 x line 3)
$ _______________
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