APPLICATION FOR REFUND 
Tax year_______ 
       Your social security number               Spouse's social security number     Mail To:

                                                                                 CITY OF WOOSTER
First name and initial                           Last name                       INCOME TAX DEPT
                                                                                 PO BOX 1088
If joint return, spouse's first name and initial Last name                       WOOSTER OH 44691
                                                                                 www.woosteroh.com
Address

                                                                                 QUESTIONS?
City, State & Zip Code                                                           (330) 263-5226

       No refund will be issued without the proper documentation indicated by reason for claim
Reason for Claim
       Under 18 years of age. Date of Birth: __/__/__. Attach W-2 and copy of your birth certificate or a copy of your driver's license;
1      complete lower section of this page. If you were under 18 for part of the year your employer must complete the Employer's Certification on 
       page 2 certifying your wages earned prior to turning 18.

2      Days worked outside of Wooster for which tax was withheld. Attach W-2, complete calculation of days worked outside
       Wooster, log of days worked outside Wooster on page 2, and employer certification must be completed, DO NOT complete claim below.

3      Other (explain). Attach W-2 and other documentation supporting your claim. Your employer must sign Employer Certification on page 2

Claim
1 Wages. Box 5, or 18 from your W-2.                                                              1
2   Income Not Taxable. Under 18 Wages, Other etc.                                                2 (                                             )
3 Adjusted Taxable Income. Subtract line 2 from line 1.                                           3
4 Wooster Income Tax 1.5%. (.015) of line 3.                                                      4
5 Wooster Tax Withheld. Enter amount in box 19 of your W-2                                        5
6 Estimated Tax Payments or Overpayments from Prior Years.                                        6
7 Total Credits. Add lines 5 and 6.                                                               7
8 Amount of Refund Requested. Subtract line 4 from line 7.                                        8

Taxpayer's Signature
Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct, 
and complete. I understand that this information may be released to the tax administrator of the municipality of residence or other 
municipalities in which work was performed or the Internal Revenue Service. I further understand that if I have a balance due for prior 
year(s), this refund will be applied to that balance before issuance. 

                                                                                     To avoid delays or a denial of your refund:

                                                                                 Complete required fields as indicated by 
Taxpayer's Signature                                       Date                  "Reason for Claim"

                                                                                 Attach all required documents indicated 
Spouse's Signature                                         Date                  under your "Reason for Claim"

                                                                                 All incomplete applications will be returned 
Preparer's Signature               Phone Number Date

Do you authorize your preparer to contact us regarding this return?              Yes  No 

Calculation of Days Worked Outside of Wooster
1 Total workdays available. If you normally work a 5 day work week 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 # 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 from line 1                                                              3
4 Days worked out of town. A log of days out, destination, and reason for travel must be included (see below).
If you worked more than 12 days in another municipality (city or village) that has an income tax, attach a copy of the 
tax return filed with that municipality.                                                                               4
5 Days worked in the municipality for which tax was withheld. Subtract line 4 from line 3.                             5
6 Total days taxable to the City of Wooster. Add line 2 & line 5                                                       6
7 Percentage of wages earned in the municipality. Divide line 6 by line 1.                                             7
8 Total municipal taxable wages. Enter the larger of Box 5 or 18 from your W-2.                                        8
9 Wages taxable to municipality for which tax was withheld. Multiply line 7 by line 8.                                 9
10 Wages not taxable to the municipality for the which tax was withheld. Subtract line 9 from
line 8.                                                                                                                10
11 Amount of over withholding claimed. Multiply line 10 by 1.5% (.015).                                                11
                                          Log of Days Out
List the names of the municipalities/locations where you worked while traveling, the reason for your travel, and 
the number of days worked at your travel destination. Your own worksheet is acceptable. Use additional paper if 
necessary. 
Work Location                             Reason                                   #Days
1
2
3
4
5
6
7
8
9
10
Total number of days worked out of Wooster
Employer Certification
The undersigned employer representative states that during the year referenced above the employer withheld municipal income tax from 
the above named employee in excess of the employee's liability as calculated above; that the above referenced employee was employed 
during the period referenced above; that the employer has examined this claim for refund in its entirety including any accompanying 
schedules and statements; and that the employer representative can attest that the information reported on this claim is true and accurate. 
In addition, the undersigned employer representative verifies that no portion of the over-withheld tax has been or will be refunded directly to 
the employee by the employer, and that no adjustments to the employer's withholding account related to this claim have been or will be 
made.  

Representatives' Signature                Title                                    Date

Print Representative's Name               Phone Number
Taxpayer's Signature
Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct and 
complete. I understand that this information may be released to the tax administrator of the municipality of residence or the Internal 
Revenue Service. I further understand that if I have a balance due for prior year(s), this refund will be applied to that balance before 
issuance. 

Taxpayer's Signature                      Date

Spouse's Signature                        Date

Preparer's Signature                      Date                                     Phone Number
Do you authorize your preparer to contact us regarding this return?        Yes        No   