Form Ir-22 - City Income Tax Return For Individuals - 2012 Page 2
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1
2
3Name(s) as shown on Page 1
Primary Social Security Number
Non-Wage Income
C
Column O
Column P
Column S
Column Q
Column R
O
OTHER INCOME FROM FEDERAL
CITY
TOTAL OTHER INCOME (OR LOSS)
INCOME (OR LOSS) FROM FEDERAL
RENTAL INCOME (OR LOSS) FROM
D
PARTNERSHIP K-1 - ATTACHED
FEDERAL SCHEDULE E OR
IF GREATER THAN ZERO, CARRY TO PAGE 1,
SCHEDULE C AND/OR F - ATTACHED
E
COLUMN C.
SCHEDULE Y - ATTACHED
Claim for Refund and Adjustments to Taxable Wages
Reason for Adjustment (Explain fully)
Resident Address for this period
Adjustments to Taxable Wages
Part 1
1. If you are claiming employee expenses from Federal Form 2106, enter your total wages from that
1
job here. Do not include wages included on Lines 14 or 23 below. See instructions..................................
2. Employee business expenses from Federal Form 2106. Do not include 2106 expenses reported on
2
Lines 15 or 24 below. Attach a copy of the 2106 and Federal Schedule A. See instructions..................
3. Subtract Line 2 from 1. If less than zero, enter zero. List this figure in Part A of Page 1 along with
3
any other taxable wages you or your spouse earned............................................................................................................................
4. If you were under the age of 18 for all or part of the year, enter your total wages for the year....................
4
5. 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
5
here:
..........................................................................................................
6. Subtract Line 5 from 4. List this figure in Part A of Page 1 along with any other taxable wages you
6
or your spouse earned..........................................................................................................................................................................
7
7. If city tax was improperly withheld from your wages, enter your total wages from that employer ................
8. Income upon which tax was improperly withheld by employer.
Complete Part 2 below
..........................
8
9. 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 .........................................................................................................................................................................
9
10
10. If city tax was improperly withheld from your wages, enter your total wages from that employer ...............
11. Income from short-term disability withheld by employer after 7/1/07 ..........................................................
11
12. Income from long-term disability withheld by employer ...............................................................................
12
13. Subtract Lines 11 and 12 from 10. List this figure in Part A of Page 1.
Complete Part 2 below
..................................................
13
14. If you were a nonresident railroad employee or nonresident over-the-road truck driver assigned
14
duties only within Ohio, enter your total railroad or driving wages here.......................................................
15
Attach a copy of the 2106 & Fed Sch A
15. Enter the amount of 2106 expenses related to this income.
16. Line 15 from 14. If less than zero, enter zero..............................................................................................
16
17. Multiply the amount of Line 16 by 10% (.10). List this figure in Part A of Page 1 along with any other
..............................................................................................
17
taxable wages you or your spouse earned.
Complete Part 2 below
If you were a nonresident employee who worked part of the year outside the city for which your employer withheld city tax
complete Lines 18 through 28. Attach a list of the dates and locations worked out
. See instructions.
18. Enter the total number of vacation days taken during the entire year...........................................................
18
19. Enter the total number of holidays for the entire year...................................................................................
19
20. Enter the total number of sick leave days taken during the entire year........................................................
20
21. Add Lines 18 through 20..............................................................................................................................
21
22. Subtract line 21 from 260 (total workdays in a year) (see instructions) .......................................................
22
23
23. Enter your total wages for this job for the year..............................................................................................
24
24. Enter the amount of 2106 expenses related to this income.
Attach a copy of the 2106 & Fed Sch A
25
25. Subtract Line 24 from 23. If less than zero, enter zero................................................................................
26
26. Divide Line 25 by the number of days shown on Line 22.............................................................................
27
27. Enter the number of days worked in the city (Line 22 less total days worked out).......................................
28. Multiply Line 26 by Line 27. List this figure in Part A of Page 1 along with any other taxable wages
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you or your spouse earned.
Complete Part 2 below
....................................................................................................................
Certification by Employer Regarding Adjustments to Taxable Wages
Part 2
Print Form
Employer certification is required to claim adjustments on Lines 7 through 28 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 28 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
Reset Form
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.
Name of
Employer’s
Date
Employer
(
)
Phone No.
Official’s Name Printed
Official’s
Signature
Title
Rev. 9/28/12
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