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CITY OF BLUE ASH NON RESIDENT REQUEST FOR REFUND (513) 745 8516‐
Fax (513) 745 8651‐
TTY (513)745 6251‐
Your First Name and Middle Initial Last Name blueashtax@blueash.com
Your social security number Tax year of claim
Current home address (number and Street) Apt #
City, State and Zip Code Phone Number Email address
Reason for Claim:
No refunds will be issued without proper documentation indicated by reason for claim
1. Days worked outside of municipality for which the employer withheld tax. Attach a copy of your W 2 Form, ‐ a completed Log of Days Out
Worksheet on page 2, and a completed Calculation for Days Worked out of Blue Ash on below. In addition, your employer must complete and sign
the Employer Certification below and initial and date each page of the provided Log of Days Out Worksheet.
2. Employer withheld at a rate higher than the municipality’s tax rate of 1.25%. Attach a copy of your W ‐ 2 Form. Your employer must complete
and sign the Employer Certification Below.
3. Withheld by mistake for the City of Blue Ash. Attach a copy of this form along with a copy of your W 2. A ‐ letter on company letterhead signed
by a supervisor stating the withholding was withheld in error and state the actual work location where work was performed.
4. Other (indicate reason). Attach W 2 Form‐ and other applicable documentation. Your employer must complete and sign the Employer
Certification below.
Refund Calculation Part 1 :
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 must provide a separate breakdown of these days on page 2. 2
3 Total days actually worked. Subtract line 2 from line 1 3
4 Days worked out of Blue Ash. A log of days out, destination must be included. For purposes of this refund claim,
if you worked in another municipality that has an income tax, the wages earned in that municipality are subject
to tax in the municipality. 4
5 Days worked in Blue Ash. Subtract line 4 from line 3 5
6 Percentage of wages earned in Blue Ash. Divide line 5 by line 3 6
7 Total municipal taxable wages. Enter the larger of Box 5 or 18 from your W 2 ‐ 7
8 Wages taxable to Blue Ash. Multiply line 6 by line 7 8
9 Tax due to Blue Ash. Multiply Line 8 by tax rate of 1.25% 9
10 Tax withheld to the City of Blue Ash. Box 19 of provided W ‐ 2 10
11 Refund due. Subtract line 9 from line 10 11
Refunds will not be processed and will be returned in the event that the below employers signature is not completed in its entirety including signature,
title, date and phone number. Also, please note that the person applying for a refund cannot authorize their own refund. All documents will be
returned and no refund will be processed if either of these situations occur.
Employer Representative’s Explanation of Reason for Refund and Signature
The undersigned employer representative state that during the referenced tax year 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 tax year as 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 undersign 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.
Representative’s Signature Print Representative’s Title Date
Printed Representative’s Name Representative’s Phone Number
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