City Of Fairfield Application For Sign Permit Form
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COMPLETE, PRINT AND MAIL IN THIS FORM
City of Fairfield
TRUCK DRIVER REFUND REQUEST FORM FOR TAX YEAR _________
Taxpayer(s) Name: ________________________________
S.S. #: ________________
Name of Employer: ______________________________________________
This form is intended for truck drivers whose primary route is outside of Fairfield City limits. In
order to receive a refund, complete this form and have your supervisor and/or payroll manager sign
the bottom of this form and attach it to your return. We no longer require a separate letter or itinerary
from your employer. As long as your employer withheld correctly, you will receive ninety percent
(90%) of your withholdings back as a refund per the City of Fairfield’s Income Tax Rules and
Regulations.
ALLOCATION OF WAGE AND SALARY INCOME:
1.
Total income paid during the year:
(gross salary or the highest amount on your W-2;
deferred compensation and other compensation included, should be on Line 1 on your
__________
Fairfield return)
2.
Tax Liability (line 1 times 1.5%):
__________
0.00
3.
Total amount withheld for Fairfield:
__________
4.
Difference: if zero go to line 5; if not, contact our office:
__________
0.00
5.
Fairfield Taxable Income Wages:
(should be Line 3 on your Fairfield return)
a.
Line 1 _________ times ten percent (10%) =
__________ FF WAGES
0.00
***
Days-out-of-town Wages:
(should be Line 2 on your Fairfield return)
b.
Line 1 _________ times ninety percent (90%) =
__________ DOT WAGES
0.00
***
When applicable, the city/village of residence will be notified of your refund, as tax may be
due to them.
As the supervisor and/or payroll manager for the above, I concur that all of the above
information, as submitted by the employee, to be accurate.
_______________________________________
_____________________
__________
Name and Title
Phone Number
Date
INCOME TAX DIVISION
5350 Pleasant Avenue, Fairfield, Ohio 45014 513-867-5327 (TDD-867-5392)
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