Form Ir-22 - City Income Tax Return For Individuals

Name(s) as shown on Page 1

Your Social Security Number

Non-Wage Income

You must attach all applicable schedules from your Federal return.

Column Q

Column O

Column P

Column R

Column S

OTHER INCOME FROM FEDERAL

RENTAL INCOME (OR LOSS) FROM

TOTAL OTHER INCOME (OR LOSS)

CITY

INCOME (OR LOSS) FROM FEDERAL

FEDERAL SCHEDULE E -

K-1 - ATTACHED

IF GREATER THAN ZERO, CARRY TO PAGE 1,

SCHEDULE C AND/OR F - ATTACHED

ATTACHED

COLUMN C.

Losses may only be taken against equal or greater amount of other unincorporated business income earned in the same city or against other unincorporated business

income taxed by city of residence.

Claim for Refund and Adjustments to Taxable Wages

You must complete and sign Page 1 to claim a refund.

Reason for Adjustment (Explain fully)

Resident Address for this period

Adjustments to Taxable Wages

Part 1

If you are claiming employee expenses from Federal Form 2106, enter your total wages from that

job here. Do not include wages included on Lines 10 or 19 below. See instructions.........................

Employee business expenses from Federal Form 2106. Do not include 2106 expenses reported on

Lines 11 or 20 below. Attach a copy of the 2106. See instructions..................................................

Subtract Line 1 from 2. If less than zero, enter zero. List this figure in Part A of Page 1 along with

any other taxable wages you or your spouse earned..........................................................................

If you were under the age of 18 for all or part of the year, enter your total wages for the year............

Wages earned while under the age of 18. Attach a copy of your birth certificate, a copy of your

driver’s license or a notarized statement from either parent stating your birthday. Enter date of birth

here: _____/_____/_____.................................................................................................................

Subtract Line 5 from 4. List this figure in Part A of Page 1 along with any other taxable wages you

or your spouse earned.......................................................................................................................

If city tax was improperly withheld from your wages, enter your total wages from that employer .......

Income upon which tax was improperly withheld by employer. Complete Part 2 below............ ......

Subtract Line 8 from 7. List this figure in Part A of Page 1 along with any other taxable wages you

or your spouse earned ( WARNING : Employer may have to refund. See instructions.)....................

10. If you were a nonresident railroad employee or nonresident over-the-road truck driver (other than

local delivery) enter your total railroad or driving wages here............................................................

11. Enter the amount of 2106 expenses related to this income. Attach a copy of the 2106 ..................

12. Subtract Line 11 from 10. If less than zero, enter zero.....................................................................

13. Multiply the amount of Line 12 by 10% (.10). List this figure in Part A of Page 1 along with any other

taxable wages you or your spouse earned. Complete Part 2 below...............................................

If you were a non-resident employee who worked part of the year outside the city for which your employer withheld city tax

complete Lines 14 through 24. Attach a list of the dates and locations worked out. See instructions.

14. Enter the total number of vacation days taken during the entire year.................................................

15. Enter the total number of holidays for the entire year.........................................................................

16. Enter the total number of sick leave days taken during the entire year...............................................

17. Add Lines 14 through 16....................................................................................................................

18. Subtract line 17 from 260 (total workdays in a year) (see instructions)...............................................

19. Enter your total wages for this job for the year...................................................................................

20. Enter the amount of 2106 expenses related to this income. Attach a copy of the 2106...................

21. Subtract Line 20 from 19. If less than zero, enter zero......................................................................

22. Divide Line 21 by the number of days shown on Line 18...................................................................

23. Enter the number of days worked in the city (see instructions)..........................................................

24. Multiply Line 22 by Line 23. List this figure in Part A of Page 1 along with any other taxable wages

you or your spouse earned. Complete Part 2 below.......................................................................

Certification by Employer Regarding Adjustments to Taxable Wages

Part 2

Employer certification is required to claim adjustments on Lines 7 through 24 above. Your request for refund will not be considered valid without a completed

employer certification. A separate certification is required for each job for which you are claiming adjustments on Lines 7 through 24 above.

I/We certify that the employee referenced on this form was employed by the undersigned during the year referenced on this tax return; that the employee was

either not working inside the corporate limits of the city or city tax was improperly withheld; that no portion of the tax withheld has been or will be refunded to the

employee; and that no adjustment has been or will be made in remitting taxes withheld to the city.

By:

Name of Employer

Official’s Signature

Official’s Name Printed

Employer’s Phone

Title

Date

IR-22 (Rev. 9/99)

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