Days-Out-Of Town Refund Request Form For Tax Year - City Of Fairfield
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1is an automatically calculated field
COMPLETE, PRINT AND MAIL IN THIS FORM
City of Fairfield
DAYS-OUT-OF-TOWN REFUND REQUEST FORM FOR TAX YEAR _________
Taxpayer Name: __________________________________ S.S. #: ________________
Name of Employer: ________________________________ Position: ____________________
Part I
Days Worked Calculation:
1.
Total days in the year:
__________
2.
Number of Saturdays and Sundays:
__________
0
3.
Total days worked in year (line 1 minus line 2)
__________
Part II
Allocation of Wage and Salary Income:
4.
Total days worked outside of Fairfield
__________
(Attach a complete itinerary substantiating days not in Fairfield)
0
5.
Total days worked in Fairfield
__________
(Line 3 minus Line 4)
Note: ALL holidays, vacation and sick leave MUST BE INCLUDED in this total.
6.
Fairfield Taxable Income Percentage:
(should be multiplied by Line 1 on your Fairfield
return and put on Line 3 on your Fairfield return)
a.
Line 5 _________ divided by Line 3 _________ =
__________ FF%
0.00%
0
0
Days-out-of-town Percentage:
(should be multiplied by Line 1 on your Fairfield return and
***
put on Line 2 on your Fairfield return)
b.
Line 4 _________ divided by Line 3 _________ =
0
__________DOT%
0.00%
***
When applicable, the city/village of residence will be notified of your refund, as tax may be
due to them.
As the supervisor and/or payroll manager for the above, I concur that all of the above
information, as submitted by the employee, to be accurate.
_______________________________________
_____________________
__________
Name and Title
Phone Number
Date
INCOME TAX DIVISION
5350 Pleasant Avenue, Fairfield, Ohio 45014 513-867-5327 (TDD-867-5392)
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