Non-Resident Employee Refund Form - Findlay Income Tax Department

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Findlay Income Tax Department
PO Box 862, Findlay, Ohio 45839-0862
Ph: 419-424-7133 Fx: 419-424-7410
Non-resident Employee Refund Form
(for non-residents and part-year residents only)
Name _____________________________________________________________ SSN __________-_______-____________
______________________________________________________________________________________________________
Current residence address
City
State
Zip
20
For tax year:
_______.
Employer ____________________________________________________________ (attach W-2)
Is your position with the employer salaried?
Yes
No
___________/___________/___________
___________/___________/___________
Date you started working for this employer
Date you stopped working for this employer, if applicable
Is your residence address outside the Findlay City limits?
Yes
No
(If you lived in Findlay the entire year, you are not eligible for a refund.)
Did you reside at the above address for the entire period you worked for the employer that withheld the tax?
Yes
No
If not, provide your old address and the applicable move dates below.
______________________________________________________________________________________________________
Old address
City
State
Zip
___________/___________/___________
___________/___________/___________
Date you moved to the old address
Date you moved from the old address
1. Enter the number of hours you worked for this employer during the year. If for the entire year, and you are a salaried
employee, use 2,080.
1. ____________ Hours
2. For the period during which you lived outside of the Findlay City limits, enter the number of hours worked or performed
services for this employer outside the Findlay City limits. Do not include vacation, holiday, or sick leave hours.
If you are a salaried employee, these must be weekday hours.
2. ____________ Hours
÷
line 1). Enter the percentage of hours you worked outside the Findlay City limits.
3. Divide line 2 by line 1 (line 2
Forward this percentage to line 6a on the front of the Findlay Income Tax Return.
3. ____________ %
Briefly explain what you do for this employer (i.e., drive truck, route delivery, etc.) _____________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
I certify that the information shown on this
________________________________________________________________
statement is true, correct, and complete.
Employee’s signature
Phone
Date
This calculation appears to be a fair & reasonable
representation of the non-resident employee’s
time worked outside of the Findlay City limits.
________________________________________________________________
Immediate supervisor’s signature
Phone
Date
04/2012

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