DAYS WORKED OUT OF WESTERVILLE 
                                                     CLAIM FOR REFUND 
                                                          TAXYEAR 

                                              **W2 MUST BE ATTACHED** 

Name of  A pplicant _____________________________________ _ 
Current  A ddress  ______________________________________ _ 
City State  & Z ip  _____________________________________  _ 
Social Security Number  ___________________ _

Tax Year -------             Salary$  _ ____ _                                       Tax Withheld $  _______ _ 

_______ _ Days worked out (Attach list of dates &                 locations) 
Vacation __  _  days  +  Holiday ___  days  +  Sick leave_ days                  Total (1) __  _ 

260 days less (1) ___ _         =    (2) ____ days worked 

$ _____ _           Salary/ (2)                      (3)  ____ _ average rate per day worked
(2)  _ ___ less ___ days worked out of Westerville                (4) ___ days in Westerville

(4) __ _            X  (3)  __ _              ( 5 )$  _ __  _  taxable wages for Westerville 

(5 )$  __  _        X  (**Year s=Tax Rate)  _ _____                                  Westerville tax due$  ______ _ 

                                                                                     REFUND DUE               $ ______ _ 
Claimant declares that after examining  this form that it is to the best of his/her knowledge, true, correct and complete. Claimant further states 
that said refund has not been received by him/her. 

Signed  ____________________  Date _______ _ Phone _________  _ 

                                              Employer Certification 

I/We Herby certify that the above employee was employed by the undersigned during the period for which employee makes claim for refund 
and that the total amount of$  ___ was withheld for the year __ ; that during the period claimed above  said employee was not  working 
inside the corporate limits of the City; that no portion of said tax withheld has been or will be refunded to said employee, and that no adjustment 
has been or will be made in remitting taxes withheld to the City. 

Name of Employer                            FID#                            Date                Phone 

Name of Authorized Personnel                                        Signature & Title of Authorized Personnel 
Mail completed request &     supporting documentation for refund to: City of Westerville, Income Tax Division 
                                                                         PO Box 130 
                                                                         Westerville OH 43086-0130 
                                                                         Tel# (614) 901-6420 Fax# 901-6820 
                                                                         www.westerville.org/incometax 
                                     NOTICE: This refund may result in a balance due to your resident City and/or 
                                     Federal & State tax return. 
                                     Employer Certification is required by City of Westerville 
(Rev 12/21)                          Please allow 90 days for processing of your refund request fro mthe due date.