Tax Year Name(s) Primary Social Security Number
Address
Refund Worksheet (if applicable) Attach completed worksheet to the City Tax Form
For use by individuals seeking a refund of municipal tax paid to a CCA member municipality.
Type of Refund: Check the appropriate line.
_____ A. Under 18 years of age$WWDFK:DQGDFRS\RI\RXUELUWKFHUWL¿FDWHRUGULYHU¶VOLFHQVH
NOTE: Dresden, Hamilton, Montpelier, Munroe Falls, New Paris, Oakwood, Obetz, Phillipsburg, Riverside and West Alexandria have no minimum age.
Geneva-on-the-Lake uses 15 as a minimum age. Grand River, Rushsylvania, and West Milton use 16 as the minimum age. New Carlisle
individuals 16 and 17 years old who earn $2,500.00 or more are subject to the tax.
If you reached the minimum age to pay tax during the year, attach a letter from your employer that provides a breakdown of how much was earned before
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_____ B. Days worked outside of municipality for which the employer withheld tax - Attach Form W-2 and a travel log listing the date, place and business
purpose of travel, indicating the number of business days out ____/260 days. A letter from your employer verifying the days worked out of the municipality
is required. The letter must be on company letterhead, include an authorized signature, title, and telephone number.
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to arrive at the amount of income to be excluded from tax:
days worked out of the municipality / 260 or total working days x local wages = amount excluded
Saturdays, Sundays, sick days, vacation days and holidays are not to be counted as days worked out of the municipality. Total working days should be
260, unless you worked a partial year. On the income earned while traveling, you will owe tax at the full percentage rate to your residence municipality.
Residents of CCA member municipalities must complete page 1 of the City Tax Form.
_____ C. Other (explain) ________________________________________________________________________________________________________
You must explain in detail and attach complete documentation. If you did not work in the municipality shown on your W-2, indicate the name of the work
city. A letter from your employer verifying the refund claimed is required. The letter must be on company letterhead, include authorized signature, title, and
telephone number.
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COMPUTATION OF OVERPAYMENT
Line 1: Enter the amount of local wages that your employer showed on your Form W-2. Wages that are deferred for Federal and State
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Line 2: Enter the amount of wages that are to be excluded from tax.
Line 3: Subtract the amount on Line 2 from the amount shown on Line 1.
Line 4: Multiply the corrected net taxable income by the employment municipality tax rate.
Line 5: The amount of tax withheld by your employer.
Line 6: A prior year amount taken as a credit.
Line 7: Estimated payments made directly to CCA during the year.
Line 8: Add lines 5, 6 and 7.
Line 9: Subtract Line 8 from Line 4. Worksheet and documents must be attached.
1.) Wages as reported on Form W-2 (Must attach W-2) ………………………………..……….............……............……….…$________________
2.) Less wages not subject to tax ………………………………………………………………….……........…………............…..$________________
3.) Net taxable wages ………………………………………………………………………………………….....….............…….….$________________
4.) Corrected tax ……………………………………………………………………………………………………............….…...….$________________
Less: 5.) Tax Withheld ……………………………………………........................................................................….…..$________________
6.) Prior Year Credit ……………………………............................................................……….........…….….….$________________
7.) Estimate Paid …………………………………………................................................................………….…$________________
8.) Total (lines 5, 6 and 7) ……………………………………………….............……………………............…..….$________________
9.) Refund requested: enter here and Section A Line 11b on the City Tax Form. Amounts $10.00 or less will not be refunded....$________________
ENTER YOUR SOCIAL SECURITY NUMBER(S), NAME(S) AND ADDRESS ON THE WORKSHEET AND THE CITY TAX FORM. CHECK THE REFUND BOX
IN THE UPPER RIGHT CORNER ON THE CITY TAX FORM.
ATTACH THIS REFUND WORKSHEET AND REQUIRED DOCUMENTATION TO THE CITY TAX FORM.
Sign and mail the City Tax Form to CCA - Division of Taxation, P.O. Box 94520, Cleveland, OH 44101-4520
_____________________________________________
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_____________________
DATE
I declare that the worksheet, to the best of my knowledge, is true and complete.
