"Refund Request Form" - City of St. Marys, Ohio

Refund Request Form is a legal document that was released by the Ohio Department of Taxation - a government authority operating within Ohio. The form may be used strictly within City of St. Marys.

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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
New Bremen
1.5%
18 years of age
Osgood
1.0%
16 years of age
Botkins
1.5%
17 years of age
New Knoxville
1.5%
17 years of age
Russia
1.5%
17 years of age
Minster
1.5%
18 years of age
North Star
0.5%
16 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 nu mber of Vacation Days, Holidays, Sick Days, Personal 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 d ays to you r
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".
Th is figure represents your "D ays On The Job in City/V illage of
___________________.
Number of Work Days
Less: Vacation Days
(
)
Less: Sick Days
(
)
Less: Holidays
(
)
Less: Personal Days
(
)
TOTAL AVAILABLE WORK DAYS
Total Available Work Days
(A)
(
)
(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 pay stub 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.
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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
New Bremen
1.5%
18 years of age
Osgood
1.0%
16 years of age
Botkins
1.5%
17 years of age
New Knoxville
1.5%
17 years of age
Russia
1.5%
17 years of age
Minster
1.5%
18 years of age
North Star
0.5%
16 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 nu mber of Vacation Days, Holidays, Sick Days, Personal 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 d ays to you r
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".
Th is figure represents your "D ays On The Job in City/V illage of
___________________.
Number of Work Days
Less: Vacation Days
(
)
Less: Sick Days
(
)
Less: Holidays
(
)
Less: Personal Days
(
)
TOTAL AVAILABLE WORK DAYS
Total Available Work Days
(A)
(
)
(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 pay stub 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
A SEPARATE FORM
106 E. SPRING STREET
MUST BE FILED FOR
ST. MARYS, OHIO 45885
EACH EMPLOYER AND
419-394-3303, ext. 107
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_________________________________
D
ate______________________
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____________________
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