Non-Resident Employee Refund Application Form

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Amt. Refund ___________
NON-RESIDENT EMPLOYEE
Check No. _____________
REFUND APPLICATION
Mailed
_____________
For Days Worked Out of Warren
Approved By ___________
Acct. No. _____________
During the year ______, my employment with ________________________________________
located or based in the City of Warren, required me to perform services both inside and outside
the corporate boundaries of the City as follows:
Total Days Paid 52 Weeks @ 5 days per Week or 260 Working Days:
(Or dates of employment – beginning _______________through _______________________).
Working Days Outside Warren
__________________
To Be Refunded
. Do not include vacation, sick,
(COMPLETE THE CALENDAR IN DETAIL and attach to this refund request
holiday, weekends or other paid non-working days.)
Working Days in Warren
__________________
Taxable
Warren Tax Withheld from W-2
__________________
Attach copy of W-2
Under penalties of perjury I hereby certify that the information provided herein is true, correct,
and complete to the best of my knowledge and belief.
_____________________________________
____________________________
Employee’s Signature
Date
________________________________________________________
__________________________________________
Print Employee’s Name
Social Security Number
________________________________________________________
__________________________________________
Employee’s Home Address
Daytime Phone Number
________________________________________________________
Employee’s City of Residence
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
EMPLOYER’S VERIFICATION
Under penalties of perjury I the undersigned state that I have examined this claim for refund, including the
accompanying itinerary, and to the best of my knowledge and belief, this refund claim is true and correct. The days
outside of Warren so indicated reflect actual working days and do not include vacation, sick, holiday, weekends or
other paid non-working days. No portion of said tax withheld has been or will be refunded to said employee; and
that no adjustment has been or will be made in remitting taxes withheld to the City of Warren, Ohio.
_____________________________________
__________________________
Employer’s / Manager’s Signature
Date
________________________________________________________
_______________________________________
Print Employer’s / Manager’s Name
Title
Forms re
a
availab
le at
________________________________________________________
Employer’s / Manager’s Phone Number and Extension
or by calling (33
0) 841 - 2551
Income Tax Division, P.O. Box 230, Warren, OH 44482

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