City of Mansfield, Ohio Income Tax
                                     Non-Resident Employee Refund Application Tax Year - 2022

Name of Applicant: ____________________________ Social Security Number: _______________________

Current mailing address: ________________________________________________________________________

A - Days worked out calculation
  1 Total workdays available.  If you normally work a 5 day workweek and you worked for your employer for
    the entire year, enter 260 (52 weeks times 5 days).  Otherwise enter the number of days you normally
    worked in a week times the number of weeks worked (cannot exceed 260).                                  1
  2 Days not worked.  Enter total number of days included on line 1 that you did not work due to holidays
    personal days, sick days, and vacation days.                                                            2
  3 Total days actually worked.  Subtract line 2 form line 1                                                3
  4 Days worked outside of Mansfield.  A log of days out, destination and reason for travel must be included
    If you worked in another city that has an income tax, the wages earned in that city are subject to tax
     in that city.  Use other side of this sheet for log.                                                   4
  5 Days worked in Mansfield for which tax was withheld. Subtract line 4 from 3                             5
  6 Percentage of wages earned in Mansfield.  Divide line 5 by line 3                                       6
  7 Total city taxable wages.  Enter the larger of Box 5 or 18 from your W-2                                7
  8 Wages taxable to Mansfield for which city tax was withheld.  Multiply line 6 by line 7                  8
  9 Wages not taxable to Mansfield for which tax was withheld.  Subtract line 8 from line 7.                9
10 Amount of over withholding claimed.  Multiply line 9 by 2% (.02)                                         10

This section to be completed by individuals working outside Mansfield during tax year.

                      $                                      $                                                          $
% from line 6       X (W-2 wages) line 7                  = taxable income line 8          X  2% equals                 City tax amount due

$                     $                                      $
W-2 tax withheld    less    City tax amount due              Refund amount                                  ATTACH W-2

Under penalties of perjury, I certify that the facts and allegations contained on this form and on any accompanying schedules
are true.  I understand that this information may be released to the tax administrator of the resident city and the IRS.

Employee Signature:                                          Date:                Contact phone number:

Employer Certification

The undersigned employer representative states that the above employee was employed by the undersigned during the period the
employee make claim for refund.  The employee was not working inside the corporate limits of the City during the period claimed
above.  No portion of tax withheld has been or will be refunded to employee, and no adjustment has been or will be made in
remitting taxes withheld of the City.

Name of Employer                                          FEIN                    Date                                  Phone number

Name of authorized Personnel                                          Signature and Title of Authorized Personnel

                                               City of Mansfield, Ohio Income Tax
                                     Non-Resident Employee Refund Application Tax Year - 2022

Name of Applicant: ____________________________ Social Security Number: _______________________

Current mailing address: ________________________________________________________________________

B - Employees that spend a percentage of worktime in city on a daily basis

  A)   Percent of time spent working within City             %       as prearranged with the City or certified by employer.

                                     $                     $                                                            $
% from line A                X       W-2 wages           = taxable income                                               X  2% = City tax amount due

$                                    $                     $
W-2 tax withheld             less    City tax amount due   Refund amount                                                ATTACH W-2

Under penalties of perjury, I certify that the facts and allegations contained on this form and on any accompanying schedules
are true.  I understand that this information may be released to the tax administrator of the resident city and the IRS.

Employee Signature:                              Date:       Contact phone number:

Employer Certification

The undersigned employer representative states that the above employee was employed by the undersigned during the period the
employee make claim for refund.  The employee was not working inside the corporate limits of the City during the period claimed
above.  No portion of tax withheld has been or will be refunded to employee, and no adjustment has been or will be made in
remitting taxes withheld of the City.

Name of Employer                               FEIN          Date                                                       Phone number

Name of authorized Personnel                               Signature and Title of Authorized Personnel

  Method used by employer to establish percent of time spent inside city:

C - Instructions and log worksheet for line 4 part A

1 All claims must be signed and all applicable sections completed.
2 An employee who is claiming a refund of tax withheld must attach W-2 wage statement showing
  Mansfield tax withheld.
3 Training sessions, seminars, local meetings, although they may be outside the City, do not constitute
  changes in work sites ande are not factored into determining time worked out of the City.  HOWEVER
  if your principal place of work has changed by your employer and you are working from home and you
  are a non-resident complete part A.
4 Employer's certification must be completed by authorized officer or agent.
5 No refund of less than ten dollars ($10.00) will be issued and must be requested within three years 
  from the due date of the tax year.

NOTE:  INCOMPLETE CLAIMS WILL NOT BE APPROVED AND WILL BE RETURNED TO CLAIMANT FOR CORRECTION
  Be advised that we may notify your resident city and those cities shown on your itenerary who also have 
  an income tax.  Since you are receiving a refund of taxes withheld for your base city of employement,
  the work city or city of residence may elect to pursue recovery of those dollars refunded.

  LOG OF DAYS OUT
  Work Location                     Reason                                                                     Number of days
1
2
3
4
5
6
7
8
9
10