Taxpayer Name (As shown on Page 1) Social Security #
ADJUSTMENTS TO TAXABLE INCOME
Under 18
1. If you were under the age of 18 for all or part of the year, enter your total wages for the year 1.
2. Wages earned while under the age of 18. Attach a copy of your birth certificate OR a copy of your driver’s license
Enter your date of birth here: 2.
3. Subtract Line 2 from 1; transfer this figure to Item 1 (page 1) along with any other taxable wages 3.
Improperly Withheld by Employer (Address where work physically performed):
4. If city tax was improperly withheld from your wages, enter your total wages from that employer 4.
5. Enter income upon which tax was improperly withheld by employer. Complete Certification by Employer below 5.
6. Subtract Line 5 from 4; transfer this figure to Item 1 (page 1) along with any other taxable wages 6.
Part-Year Resident
7. If you moved, enter your total wages for the year 7.
8. Enter the wages while not a resident 8.
9. Subtract Line 7 from 8; transfer this figure to Item 1 (page 1) along with any other taxable wages 9.
Days in/out of Dublin
If you were a nonresident employee, who worked part of the year outside of the City of Dublin but your employer withheld Dublin Tax
Complete lines 10 through 19. ALL days out MUST include documentation of days worked out (i.e. Calendar See Instructions)
10. Enter the total number of vacation days taken during the entire year 10.
11. Enter the total number of holidays for the entire year 11.
12. Enter the total number of sick leave days taken during the entire year 12.
13. Add Line 10 through 12 13.
14. Subtract line 13 from 260 (total workdays in a year)(See Instructions) 14.
15. Enter your total wages for this job for the entire year (Use Box 5) 15.
16. Divide Line 15 by the number of days shown on Line 14 16.
17. Enter the number of days worked OUT of the City (Figure comes from your calendar) 17.
18. Enter the total number of days worked IN the City (Subtract Line 17 from 14) 18.
19. Multiply Line 16 by Line 18; transfer this figure to Item 1 (page 1) along with any other taxable wages 19.
Complete the Certification by Employer below
Certification by Employer Regarding Adjustment to Taxable Wages
An Employer certification is required to claim adjustments on Line 4 through 19 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 4 through 19 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 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 Employer’s Phone No. Date
Official’s Printed Name Official’s Signature Title
SCHEDULE Y - BUSINESS ALLOCATION FORMULA
1. Average original cost of all real and tangible personal property owned or used by the taxpayer in the business or profession wherever
situated except leased or rented real property 1.
2. Annual rental on rented and leased real property used by the taxpayer wherever situated (multiple by 8) 2.
3. Combine Line 1 and 2 3.
4. All wages, salaries and other compensation paid to employees wherever their services are performed except compensation exempt from
municipal taxation under O.R.C 718.011 4.
5. All Gross receipts from sales made or services performed wherever made or performed 5.
Allocated Net
Profits (Column E)
