Srr Form - Claim From Non-Resident Of Stow For Tax Withheld By Employer Of Wages Earned Outside Stow - State Of Ohio
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1
220
SRR FORM
REV. 1/2004
W-2 MUST BE ATTACHED
CLAIM FROM NON-RESIDENT OF STOW
FOR TAX WITHHELD BY EMPLOYER OF WAGES EARNED OUTSIDE STOW
During the period
, 20
, through
, 20
, I was employed by
which compensated me in the amount of $
and withheld from
such compensation Stow Income Tax in the amount of $
. During this period my legal residence was
outside the City of Stow in:
Street
City, Village, Township
State
During the above period, I performed work as a
on behalf of my employer in
areas outside of Stow as follows: (Use attached form for worksheet).
Weekend spent out of town are NOT to be included as hours worked outside Stow if the employee’s
salary is based on a 40-Hour Monday-Friday work week. Vacations, holidays, sick days or travel time is
not to be included as hours worked outside of Stow.
Total number of hours worked outside Stow from worksheet
= % of time outside of Stow.
Total number of work hours in the year (52 X 40)
Signature of Employee
Date
Social Security Number
Present mailing address-if different from above
I hereby assign and transfer my rights, title and interest in this refund to my city of residence and authorize my
city of residence to accept this refund on my behalf.
TO BE COMPLETED ONLY IF EMPLOYEE IS A
RESIDENT OF A MUNICIPALITY WITH A
MUNICIPAL TAX
Signature of Employee
STATEMENT OF EMPLOYER
TO: Tax Administrator
3760 Darrow Road, Stow, Ohio 44224
Under penalty of perjury, the undersigned employer states that the above employee was employed during the
period
, 20
, through
, 20
, and that $
was withheld as Stow
Income Tax from earnings paid said employee during that period; that the employer has examined this claim for
refund $
including accompanying schedules and statements and that to the best of the employer’s
knowledge and belief this refund is true and correct; that the earnings claimed above were earned outside the
corporate limits of the City of Stow, and that no portion of said tax has been or will be refunded to said
employee by this employer.
Certified by:
Name of Employer
Date
Authorized Representative
Prepared by:
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