Refund Request Form - City of Xenia

File with Division of Taxation101 N Detroit StP O Box 490Xenia, OH 45385-0490Phone: (937) 376-7248Fax: (937) 376-8914XENIA CITY INCOME TAXRefund RequestFor Tax Year ______________Note: Tax rate prior to 2011 was 1.75%Rec’d ______________________Audit By ___________________Date _______________________PART I – TO BE COMPLETED BY CLAIMANT (see reverse side for instructions)Social Security No. _________________________________________Name ____________________________________________________Address __________________________________________________City/State/Zip ______________________________________________Address During Period Covered by Claim____________________________________________________________________From ______________ To_____________A. Employer’s Name and Address Xenia City Tax Withheld Gross Wages, Etc.Name ___________________________________ $____________________ $___________________Address _____________________________________________________________________________________________Attach Copy of Wage Statement (Form W-2)B. Job Title and Brief description of Job DutiesC. If required to travel, provide list of dates worked out of City and City where services were preformed. If not required to travel,show complete address(es) of place(s) where services were preformed. Give exact location(s) of Office, Branch, Store Warehouse, etc.Street No. _______________________________________________ City __________________________________ State ________Street No. _______________________________________________ City __________________________________ State ________The undersigned declares all information given is true and complete to the best of his/her knowledge and belief, that a refund has notpreviously been claimed or received by them for the period covered by this claim and that they were not a resident of the City ofXenia for the period from _________________________________ to _____________________________________.Information on this form will be forwarded to your city of residence.Signed: ________________________________________________________________ Date: ________________________________(Claimant’s Signature)PART II – TO BE COMPLETED BY EMPLOYER (see reverse side for instructions)EMPLOYER’S CERTIFICATIONI/We verify that during the year __________ I/We withheld City of Xenia Income Tax from the above named employee in excess oftheir liability for the tax based on the following computations:COMPUTATION OF OVERPAYMENTA. Salaries, wages, etc. Paid $_______________ on which Xenia tax withheld was $____________Income earned in Xenia$_______________ subject to City Tax at 2.25% (or 1.75% for tax years prior to 2011)Overpayment……………………………………………………………………………..$_____________$_____________B. Basis of Refund (Employer must provide all pertinent information and facts of which claim is based.) Explain method and showcomputations used to determine income earned in ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C. The employee’s address according to our records for the period covered by the claim was _____________________________________________________________________________________________________________________________________________I/We verify that no portion of said tax has been or will be refunded directly to the employee and that no adjustment to my/ourwithholding account with the City of Xenia have been or will be made to said tax.SIGNED: ______________________________________________ BY: _______________________________ DATE: ___________EmployerTitle

REFUND REQUESTGENERAL INSTRUCTIONSThis form is to be used only by non-resident individuals claiming a refund of Xenia City tax withheld in excess of theiractual liability. Designate the calendar year for which refund is claimed. If the individual has other taxable income, thestandard City Income Tax Return (Form R) must be used. If a refund is claimed for tax withheld by more than oneemployer, a separate Refund Request form must be completed for each employer.INSTRUCTIONS FOR PART I(TO BE COMPLETED BY CLAIMANT)Fill in Social Security Number, name and current address and address during period covered by claim.LINE A. List employer’s name, address Xenia City tax withheld, total salary, wages, commissions andother compensation.Attach a copy of Wage Statement (Form W-2) showing the Xenia tax withheld.LINE B. List job title and provide a brief description of required duties.LINE C. If duties require travel, provide a list of dates worked out of the City and city or cities where serviceswere performed. If traveling is not required, show where duties were performed.INSTRUCTIONS FOR PART II(TO BE COMPLETED BY EMPLOYER)A. List total compensation paid and full amount of Xenia city tax withheld. NOTE: The current Xenia tax rate is 2.25%.The tax rate prior to 1/1/2011 was 1.75%.Compute the amount to be entered in “Income Earned in the City” by multiplying the total compensation by the ratio ofactual days worked in the City to total days worked. Days worked only refers to the actual number of days on the job. Anemployee is not on the job when there is a holiday, or when he is sick or on vacation.EXAMPLE:NOTE:An employee worked 160 days in the City and 80 days out of the City, or a total of 240 workingdays. Report as wages earned in the City, 160/240 or 2/3rds of his wages (which would includevacation pay, holiday pay and sick pay), since all pay has the same relative tax location as thelocation where the employee performs his services.For employees paid on a commission basis, the ratio of commissions earned in the City to totalcommissions should be used instead of using days worked.B. Basis for Refund: A brief but complete explanation by employer is required concerning the reason for the overpaymentto be refunded. Explain method and show computations used to determine amount entered in “Income Earned in theCity.”C. Show the employee’s address as listed on the employer’s records.The “Employer’s Certification” must be signed by the employer’s supervisor or other responsible representative of theemployer who has knowledge that the information given is true and correct.NOTE: Separate requests are required if more than one employer is involved.LIMITATIONS ON REFUNDS:Taxes erroneously paid shall not be refunded unless a claim for refund is made within three (3) years from thedate on which such payment was made. For erroneously withholdings this is 3 years from the date the employerpaid the withholding to the City of Xenia.Updated 11/2011