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I N C O M E T AX D E P AR T M E N T
P.O. Box 862 | Findlay, OH 45839-0862
Ph. 419-424-7133 | Fax: 419-424-7410 | www.findlayohio.com
Non-resident and Part-year Resident Employee Refund Form
Form updated for use in 2021 tax year and thereafter. This form must be submitted with the W-2 in question and with a signed original Findlay Income Tax
Return available at www.findlayohio.com.
__________________________________________________________ __________-_______-____________ _____
First name, middle name, and last name Social Security number Year
______________________________________________________________________________________________________
Current residence address City State Zip
Is your residence address outside the Findlay city limits? Yes No (If you lived in Findlay for the entire year, you are not eligible for a refund.)
Did you reside at the above address for the entire period you worked for the employer that withheld the tax? Yes No
If you answered no, please provide your previous address and the applicable move dates below.
______________________________________________________________________________________________________
Previous residence address City State Zip
_____________/_____________/_____________ _____________/_____________/_____________
The date you moved to the previous address The date you moved from the previous address
__________________________________________________________________________________ ________________
Employer Salaried? or Hourly?
_____________/_____________/_____________ _____________/_____________/_____________
The date you started working for this employer The date you stopped working for this employer, if applicable
1. Enter the total number of days you worked for this employer at your principal place of work.
Pursuant to the Ohio Revised Code, principal place of work is defined under Section 718.011(A)(7). 1. ____________ days
Employer withholding exceptions are defined under the Ohio Revised Code Section 718.011(B).
2. My employer has not refunded any withheld taxes to me at the point of me making this request.
Circle true or false. If false, additional documentation may be required. True False
3. Divide line 1 by 260 (typical number of working days per year, divide by 261 if year
of request is a leap year) and enter the percentage of days you worked at your
principal place of work in the year on line 3. (Line 1 ÷ 260 days(261 days if leap year))
(If you did not work for this employer for the entire year, divide line 1 by the total number of days worked
for this particular employer to find the percentage to enter on line 3. If the percentage equals 100% on line 3, skip
the calculation on line 4 and use 100% on line 6a of your tax return.)
3. ____________ %
4. Subtract the percentage listed on line 3 from 100% and enter the percentage of time
worked outside of your principal place of work in the year. Forward this percentage to
line 6a on the front of the Findlay Income Tax Return. (100% - line 3) 4. ____________ line 6a %
I certify that the information shown on this
statement is true, correct, and complete. _______________________________________________________________
Employee’s signature Phone Date
This calculation appears to be a fair &reasonable
representation of the non-resident employee’s
time worked outside of the Findlay city limits. _______________________________________________________________
Immediate supervisor’s signature Phone Date
Pursuant to Ohio Revised Code 718.13(A), your information may be furnished to Tax Administrators of other Ohio municipalities, including your municipality of residence.
The Findlay City Income Tax is pursuant to Findlay City Income Tax Ordinance 194.011. For more details, you may find this on our website at www.findlayohio.com/incometax
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