General Instructions For Form As-22 Refund Request
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1General Instructions for Form AS-22 Refund Request
Notice: There is a 3-year statute of limitation on refund requests.
Contact the City of Fairborn Division of Taxation at (937) 754-3006 for information.
This form is to be used by individuals claiming a refund of city income tax withheld in excess of their actual liability. Designate
the calendar year for which the refund is claimed. If the individual has other taxable income, the standard city income tax return
(Form R-1040) must also be used. If a refund is claimed for tax withheld by more than one employer, a separate refund request
form must be completed for each employer. All forms must be submitted together.
The completed form AS-22 is to be submitted to the City of Fairborn Division of Taxation at the address shown on the front of
this form. Remember: Missing or incorrect information will delay your refund.
1.
Basis for Refund: A brief by complete explanation by the Applicant is required concerning the reason for the
overpayment. Explain method of calculation and show computations used to determine the amount of taxable city
income. If duties required travel, you must provide a list of dates and location of city or cities worked. If traveling was
not required, show where duties were performed.
2.
Refund Calculation is based on your gross compensation (including any deferred income). A copy of the W-2 must be
attached. This will be returned to you if requested.
3.
If the refund is because Fairborn tax was withheld on income earned prior to age 16, you must submit proof of age
(birth certificate or other acceptable proof).
4.
Total Days Available: (The total days available for use in this refund calculation may vary from year to year. Contact
our office for details.) For tax year 2005, the working year consisted of 260 days (Saturday and Sunday are not
considered working days). If you were not employed the full year, you must adjust your Total Days Available
accordingly (contact our office for details). Sick days, vacation days, and holiday days should be prorated in the same
way as time worked in and time worked out of the City of Fairborn (see formula below).
5.
Part B, Certification of Employer, must be completed by an authorized official of the employer. No person claiming a
refund may certify their own refund request form.
______________________________________________________________________________________________________
The formula for calculation of Fairborn taxable wages for each W-2 is:
Days on Job in Fairborn (B)
Total Available Working Days (A)
X
Gross Wages
=
Fairborn Taxable Wages
Use the area below for your calculation for the attached W-2
Total days available (260 days unless otherwise specified)
_______________________
Less vacation days
_______________________
Less sick days
_______________________
Less holiday days
_______________________
(A) insert in space below
Total Available Working Days
Less days worked out of city
_______________________
Days on the Job in Fairborn
(B) insert in the space below
__________ / __________ X $_________________________ = $ ________________________________
(B)
(A)
Gross W-2 Wages
Fairborn Taxable Wages
Enter on Part A, Line A on front page
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