Form Ir-1 - City Income Tax Return For Individuals Page 2

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Name(s) as shown on Page 1

Primary Social Security

Address during the Period Covered by this Claim:

Adjustments to Wages and Claim for Refund

PART E

ADJUSTMENTS TO WAGES -

List these figures on Page 1 in Column C of PART A

Section 1

2106 Expense Adjustment

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

(the larger of box 5 or 18 from W2)

…………………………………………………………………….

Do not include wages included on Lines 13 or 22 below. See instructions

Employee business expenses from Federal Form 2106.

…...

Do not include 2106 expenses reported on Lines 14 or 23 below. ATTACH A COPY of the 2106 and Federal Schedule A. See instructions

Taxable Wages with 2106 Deduction.

…………….……….

Subtract Line 2 from 1. If less than zero, enter zero. List this figure on Page 1 in Column C of PART A

Section 2

Under the age of 16 Withholding

If you were under the age of 16 for all or part of the year, enter your total wages for the year (

the larger of box 5 or 18 from W2)

Wages earned while under the age of 16.

……………..

ATTACH A COPY of your birth certificate or a copy of your driver’s license

Taxable Wages (

……………………….…………………………………………………...

Subtract Line 5 from 4) List this figure on Page 1 in Column C of PART A

Section 3

Partial Year Residents

Resident Dates from ______________________ to ___________________

Enter your total wages from employer (

………………………………………………………………..

the larger of box 5 or 18 from W2)

Wages earned while not a resident of Englewood

……………………..

ATTACH A COPY of a paystub closed to your move in date

Taxable Wages for Partial Year Residents (

………………………………….………….

Subtract Line 8 from 7) List this figure on Page 1 in Column C of PART A

Section 4

Tax Withholding Correction

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

the larger of box 5 or 18 from W2)

Income upon which tax was improperly withheld by employer.

……………………….

MUST COMPLETE CERTIFICATION BELOW

Taxable Wages (

Subtract Line 11 from 10) List this figure on Page 1 in Column C of PART A

Section 5

Non Resident Over-the-Road Truck Drivers, Air Carrier Employees or Railroad Employees

If you were a nonresident over-the-road truck driver or nonresident railroad employee assigned duties only within Ohio, enter

your total wages here (

…………………………………………………………………………………...

the larger of box 5 or 18 from W2)

Enter the amount of 2106 expenses related to this income

………………...

ATTACH A COPY of the 2106 and Federal Schedule A

Subtract Line 14 from 13.

……………………………………………………………………………………..

If less than zero, enter zero

Multiple Line 15 by 10% (.10).

List this figure on Page 1 in Column C of PART A MUST COMPLETE CERTIFICATION BELOW

Section 6

Non Resident working outside the city limits with Englewood withholdings

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

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

Enter the total number of sick leave days taken for the entire year …………………………………………………………………...

Add Lines 17 through 19 …………………………………………………………………………………………………………………...

Total Days Available to be outside of city — Subtract Line 20 from 260 days

…………...

(total workdays in a year) (see instructions)

Enter your total wages for this job for the year

……………………………………………………….

(the larger of box 5 or 18 from W2)

Enter the amount of 2106 expenses related to this income

………………...

ATTACH A COPY of the 2106 and Federal Schedule A

Subtract Line 23 from 22.

……………………………………………………………………………………..

If less than zero, enter zero

Divide Line 24 by the number of days shown on Line 21 ………………………………………………………………………………

Enter the number of days worked in the city

………………………………………………………...

(Line 21 less total days worked out)

Multiple Line 25 by Line 26.

………………………………………

List this figure on Page 1 in Column C of PART A MUST COMPLETE CERTIFICATION BELOW

Certification by Employer regarding Adjustments to Wages

Employer certification is required to claim adjustments on Lines 10 through 27 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 10 through 27 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 of Englewood or Englewood 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 of Englewood.

Phone Number

Date

Name of

Employer

Official’s Name Printed

Official’s

Signature

Official’s Job Title