Form Nrr - Claim For Refund Of Tax Withheld Non - Resident Of Whitehouse For Wages Earned Outside Whitehouse - Commissioner Of Taxation Village Of Whitehouse, Ohio

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NRR FORM
YEAR
MUST BE COMPLETED IN EMPLOYEE’S HANDWRITING
W-2 MUST BE ATTACHED
CLAIM FOR REFUND OF TAX WITHHELD
NON-RESIDENT OF WHITEHOUSE FOR WAGES EARNED
OUTSIDE WHITEHOUSE
During the period
, 20
, through
, 20
I was employed by
which employer compensated me in the amount of $
and withheld from such compensation
Whitehouse Income Tax in the amount of $
. During this period my legal residence was outside
the Village of Whitehouse as follows:
Street
City, Village or Township
State
During the above period I performed work as a
on behalf of my employer in areas
outside the Village of Whitehouse as follows: (Use reverse side if necessary.)
City & State
Exact date(s)
City & State
Exact date(s)
Weekends spent out town are NOT to be included as days spent outside Whitehouse if the employee’s
salary is based on a 40 hour, Monday–Friday workweek. Vacations, holidays, or sick days are not to be
included as days spent outside Whitehouse.
Total No. of days spent out of town from above
=
% of time spent out of town.
Total No. of days in the year (52 x 5)
260
Signature of Applicant
Date
Social Security Number
Present mailing address if different
I hereby assign and transfer my rights, title and interest in this refund to my village of residence and
authorize my village of residence to accept this refund on my behalf.
Signature of Applicant
STATEMENT OF EMPLOYER
TO:
COMMISSIONER OF TAXATION
VILLAGE OF WHITEHOUSE, OHIO
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
Whitehouse 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 Village of Whitehouse and that no portion of said tax has been or will be
refunded to said employee by this employer.
CERTIFIED BY:
Name of Employee
Date
Authorized Representative
PREPARED BY:
Print or Type Employee’s Name

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