Application For Income Tax Refund - City Of Lorain Income Tax Division
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1APPLICATION FOR INCOME TAX REFUND
City Of Lorain Income Tax Division
th
605 West 4
Street, Lorain OH 44052
Phone: 440-204-1002 / Fax: 440-204-1006
Email:
Web:
YEAR:
NAME:
SOCIAL SECURITY NUMBER:
ADDRESS:
INDICATE IN THE BLOCK BELOW THE TYPE OF CLAIM FILED: W-2 FORM MUST BE ATTACHED
Refund of Municipal Income Tax Withheld on Wages Earned in a Non-Taxing Community.
* Attach a travel log listing dates/places traveled for business, indicating the number of business days out ____/260days.
* Use this formula to determine the % of income to be excluded from Tax:
Days Worked Out of the City divided by the Total Working Days (260); x Local Wages = Amount Excluded
Note: Saturdays, Sundays, Sick Days, Vacation Days & Holidays are not to be counted as days worked out of the city.
Total working days should be 260 unless you worked a partial year. Refund will not exceed 75% of tax withheld.
Your city of residence will be notified of the amount of any refund.
B) Refund of Municipal Income Tax Withheld in Error. Check the reason below.
_____ Courtesy Withholding in Error; I was not a resident of Lorain at any time during the tax year shown above.
_____ Courtesy Withholding in Error; I moved out of Lorain on the following date: _________________
_____ Lorain Tax Withheld at a Rate Higher Than 2.0%
_____ Under the Age of 18: A copy of your driver’s license or birth certificate must accompany this form.
Dates of Employment: Beginning _______/_______/_______ Ending _______/_______/________
Other: (Explain) __________________________________________________________________________________
Computation of Overpayment
1. Wages as Reported on W-2 Form (Attach W-2s)
1.
2. Less Wages Not Subject to Tax.
2.
3. Net Taxable Wages
3.
4. Correct Tax [Taxable Wages x 2% or .020]
4.
5. Less Tax Withheld
5.
6. Refund Requested
6.
I declare under penalties of perjury that this claim (including any accompanying statement), has been examined by me
and to the best of my knowledge and belief is true and correct.
I authorize the disclosure of the information herein to any lawful taxing authority affected by the return.
Taxpayer’s Signature: ______________________________
Date: ______________
Phone: ____________________
EMPLOYER’S CERTIFICATION (To Be Completed By Employer)
We have reviewed the above calculations and attachments and believe them to be true and correct.
I/We verify that no portion of said tax has been or will be refunded directly to the employee and that no adjustments to my/our
withholding account with the City of Lorain have been or will be made for said tax.
Employer’s Signature: _____________________________ Title: ______________________
Date: ______________________
Company: _______________________________________ FEIN: _____________________
Phone: _______________________
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