REFUND REQUEST FORM - GENERAL INSTRUCTIONS

REFUND REQUEST FORM - GENERAL INSTRUCTIONS

WHO SHOULD FILE THIS FORM? Individuals claiming a refund of city tax withheld in excess of their liability. If a refund is claimed for tax withheld by more than one employer, a separate refund form must be completed for each employer. All forms must be submitted together.

Refund that are the result of losses against W-2 Income are not to be filed using this form.

DESIGNATIONS: The tax year and the city or village for which the tax was withheld must be stated in the spaces provided.

TAX RATES AND AGE LIMITS:

Anna	1.75%	17 years of age	Jackson Center	1.5%	16 years of age	New Knoxville	1.5%	17 years of age
Botkins	1.5%	17 years of age	Minster	1.5%	18 years of age	Russia	1.5%	17 years of age
Ft. Loramie	1.5%	17 years of age	New Bremen	1.5%	18 years of age	St. Marys	1.5%	16 years of age

COMPUTATION OF AMOUNT CLAIMED: (Note: This section applies only to those taxpayers who are filing for a refund based on the fact that they worked outside of the taxing jurisdiction for which tax was withheld.) The work year consists of approximately 260 days (Saturday and Sunday are not considered as work days). You must determine the number of week days, (Monday, Tuesday, Wednesday, Thursday, and Friday), that are included in the calendar year for which you are filing for a refund. Enter the total under "Number of Work Days". Next, total the number of Vacation Days, Holidays, Sick Days, Pesonal Days, etc., during the same calendar year for which you received compensation. Subtract this total from "Number of Work Days". This will give you your "Total Available Work Days". (Note: If you did not work for the employer the entire calendar year, you must adjust the days to your specific time period.)

Total the number of days worked out of town, (this figure will not include holidays, vacations, sick days, etc.), and state the number under "Less Days Worked Out of Town". A log showing dates and locations must be attached to document this number. Subtract this figure from "Total Available Working Days". This figure represents your "Days On The Job in City/Village of ___________________.

	Number of Work Days
	Less: Vacation Days	( )
	Less: Sick Days	( )
	Less: Holidays	( )
	Less: Personal Days	( )
	TOTAL AVAILABLE WORK DAYS
(A)	Total Available Work Days
(B)	LESS: DAYS WORKED OUT OF TOWN	( )
	DAYS ON JOB IN CITY/VILLAGE OF ______________________________

Line B Computation is obtained by dividing (B) by (A) and then multiply this figure by your gross wages as it appears on your W-2.

EXPLANATION OF REFUND: A brief but complete explanation is required concerning the reason for the overpayment to be refunded.

PART YEAR RESIDENTS: Taxable wages will be determined by a statement from the employer or paystub which shows year to date gross wages as of the date that the employee moved. Prorated wages based on a calendar year will not be accepted.

UNDER AGE TAXPAYERS: A copy of your drives license or birth certificate is required.

SIGNATURE: Required for all refunds.

PART B: CERTIFICATION OF EMPLOYER: Required for all refunds.

REFUND REQUEST FORM

Tax Year __________________

City/Village _______________________

DEPARTMENT OF TAXATION

106 E. SPRING STREET

ST. MARYS, OHIO 45885

419-394-3303, ext. 107

A SEPARATE FORM

MUST BE FILED FOR

EACH EMPLOYER AND

FOR EACH YEAR.

PART A: (To be completed by Taxpayer)

NAME OF APPLICANT_____________________________ SOCIAL SECURITY NO.___________________

CURRENT ADDRESS_________________________________________________________________________

STREET ADDRESS DURING CLAIM PERIOD____________________________________________________

Beginning and ending dates of residency at above address: From:__________________ To:_____________________

NAME OF CITY OF WHERE YOU ACTUALLY PERFORMED SERVICES FOR YOUR EMPLOYER:______________

EMPLOYER'S NAME____________________ EMPLOYER'S MAILING ADDRESS_____________________

COMPUTATION OF AMOUNT CLAIMED:

A)	Total gross wages as reported on W-2 (W-2 must be attached)	$
B)	Subtract nontaxable wages (From Line B computation above)	( $ )
C)	Total taxable income (Line A minus Line B)	$
D)	Tax due, Line C multiplied by _____% (See tax rates above)	$
E)	Subtract tax withheld as shown on attached W-2	( $ )
F)	Amount of refund claimed	$

EXPLANATION OF REFUND:__________________________________________________________________

________________________________________________________________________________________

I AUTHORIZE THE DEPARTMENT OF TAXATION TO FURNISH THE TAX DEPARTMENT FOR MY CITY OF RESIDENCE OR EMPLOYMENT, A COPY OF THIS REFUND REQUEST. THE UNDERSIGNED DECLARES THAT ALL INFORMATION GIVEN IS TRUE AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT A REFUND HAS NOT BEEN CLAIMED OR RECEIVED BY HIM/HER FOR THE PERIOD COVERED BY THIS CLAIM.

Signed_________________________________ Date______________________

PART B: CERTIFICATION OF EMPLOYER: (Must be completed by employer only)

I verify that during the tax year ______, my company withheld $____________ City tax in excess of his/her liability. The statements made above and any log attached has been reviewed by myself and found to be in keeping with my company's records. I also verify that no portion of said tax has been or will be refunded directly to the employee from my company and that no adjustments have been or will be made to my company's city tax withholding account for said tax.

Signed____________________________ Title______________________________ Date____________________