Days-Out-Of-Town (Dot) Refund Request Form - City Of Fairfield, Income Tax Division printable pdf download

Days-Out-Of-Town (Dot) Refund Request Form - City Of Fairfield, Income Tax Division

City of Fairfield

Days-Out-of-Town (DOT) Refund Request Form for Tax Year _________

Taxpayer(s) Name: ________________________________

S.S. #: ________________

Name of Employer: ______________________________________________

Part I

ALLOCATION OF WAGE AND SALARY INCOME:

Total days in the year:

______________

Number of Saturdays and Sundays:

______________

Total days worked in year (line 1 minus line 2)

______________

Part II

THIS SECTION TO BE COMPLETED BY INDIVIDUALS WHO ARE OUT OF FAIRFIELD

ON A NON-REGULAR BASIS:

Total days worked outside of Fairfield ****

______________

Total days worked in Fairfield (Line 3 minus Line 4)

______________

Note: ALL holidays, vacation and sick leave MUST BE INCLUDED

in this total.

Fairfield Taxable Income Percentage:

a. Line 5 _________ divided by Line 3 _________ = Fairfield Percentage ______________

Days-out-of-town Percentage:

b. Line 4 _________ divided by Line 3 _________ = DOT Percentage

______________

**** Include an itinerary of when and where the work was performed. When applicable, your

city/village of residence will be notified of your refund, as tax may be due to them.

The total % of Line 6b should be multiplied times your qualifying wages (generally the Medicare wages

as shown on your W-2; deferred compensation and other compensation included). This amount should be

put on Line 2 of your Fairfield return as a deduction against your total W-2 income on Line 1. Line 3 of the

Fairfield return should reflect your taxable income to Fairfield.

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.

_________________________ ______________________________ _____________ ____________

Signature

Name and Title

Phone Number Date

Rev. 9/09

INCOME TAX DIVISION

701 Wessel Drive, Fairfield, Ohio 45014 513.867.5327 Fax 513.867.5333

Days-Out-Of-Town (Dot) Refund Request Form - City Of Fairfield, Income Tax Division