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        www.springfieldohio.gov                                    INCOME TAX REFUND REQUEST 
                                                               CITY OF SPRINGFIELD, INCOME TAX DIVISION                         
                                                                                    76 EAST HIGH STREET                                Account #_______________ 
                                                                                         SPRINGFIELD, OHIO 45502                                             (FOR OFFICE USE ONLY) 
                                                                                          PHONE (937) 324-7357 
                                                                                  TaxFilingHelp@springfieldohio.gov 
 
             PLEASE REVIEW INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING FORM
                                                                                                                   
    PART A                                                                                                         
    Name                                                                                                          Social Security #  __________________ 
                                ( print first name, middle initial, last name )                                                       
    Present Address                                                                                                   Phone #  ________________________                  
                                   ( street, apt # ) 
                                                                                                                   
                                                                                                                  Email   __________________________ 
                                   ( city, state and zip code ) 
  
             SPRINGFIELD INCOME TAX RATE: 2.40%              JEDD INCOME TAX RATE: 1.00% 
                                                                                   
        REFUND CLAIMS OLDER THAN THREE (3) YEARS AFTER THE TAX WAS DUE OR PAID WILL NOT BE PROCESSED.  
  
             TAX YEAR __________    REFUND AMOUNT CLAIMED $____________ 
    
     PART B 
          Employer Name            Location Worked                                Taxable     Tax Due        Less Amount   =     Refund 
                                                                                   Income                                     Withheld                          Amount 
  
      ________________         _______________      _________                               _________                       _________    ___________ 
                                                                                                                                                                                    
        Please provide a clear and concise explanation of reason for refund: 

        _____________________________________________________________________________________________ 

        _____________________________________________________________________________________________ 
         
        EMPLOYEE AFFIDAVIT: The undersigned states that all facts and figures given on this form are true and complete to the best of                                               
        his/her knowledge and belief; that no such refund has previously been claimed or received by him/her; and understands that this 
        information may be released to the Internal Revenue Service and the municipality of residence. 
         
        Employee Signature ____________________________________________         Date ______________________ 
        ___________________________________________________________________________________________ _ 
     
    PART C 
    
    EMPLOYER VERIFICATION AND AFFIDAVIT: I hereby certify that __________________(employee name) was 
    employed by the undersigned during the period for which said employee makes claim for refund and that ______% or  
    the amount of $_____________ was withheld in excess of his/her liability based on the above stated facts and 
    calculations; and that no portion of said tax withheld has been or will be refunded directly to the employee, and no 
    adjustment in withholding remittance has been or will be made.  I further declare that the information contained herein 
    is true and correct to the best of my knowledge and belief and that I am authorized to provide this information. 
  
    Authorized Name _____________________________________  Title ______________________________________ 
                                   (Print first name, middle initial, last name)  
     
    Authorized Signature __________________________________  Date _____________________________________ 
     
    Name of Employer ____________________________________  Phone ____________________________________

                                                                                                                                 2 
                              INSTRUCTIONS 
                                      
  1.  THIS FORM IS INTENDED ONLY FOR THE USE OF NON-SPRINGFIELD RESIDENTS AND/OR THOSE UNDER 18 
     YEARS OF AGE. 
  2.  Do not combine refund claims for more than one employer.  A separate form must be completed for each employer 
     for which you are claiming a refund of income tax withheld. 
  3.  All claims must be properly signed by the claimant. 
  4.  All claimants must complete Parts A and B and attach copy of W-2 showing Springfield withholding and box 5 
     Medicare wages. 
  5.  Unless you are under the age of 18, or unless your employer has submitted a list of employees who are eligible for 
     a refund, you must have an authorized officer or agent of your employer complete Part C of this form. 
  6.  Refund claims for persons under 18 years of age must include verification of the exact birth date of claimant, i.e., 
     photo copy of birth certificate, driver’s license, or state issued identification card. 
  7. You must file a City of Springfield Income Tax Return in place of this form if: a)   you were a resident of the City of 
     Springfield for any part of the tax year in question; or  b)you are a Springfield resident whose 18  birthdaythoccurred 
     during the tax year in question.  For these situations, additional documentation will be required, including but not 
     limited to copies of pay stubs, verification of move dates, proof of date of birth, and/or copies of Federal Schedules C 
     and/or E. 
  8. You must file a City of Springfield Income Tax Return in addition to this form if: a)      you were a part year 
     Springfield resident and worked in another city; or  b)you owned rental property located inside the City of Springfield or 
     you were self-employed and conducted business inside the City of Springfield during the tax year in question. 
  9.  No refunds of less than $10.01 will be issued. 
  10. Refund claims will not be honored beyond three (3) years from the date the taxes were due or paid, whichever is later. 
  11. Please allow ninety (90) days for processing your completed refund claim. 
     ***PLEASE NOTE: INCOMPLETE CLAIMS CANNOT BE PROCESSED AND WILL BE RETURNED TO CLAIMANT*** 
   ________________________________________________________________________________________________ 
   The following worksheet is to be completed only by those claiming specific days worked outside the City of 
   Springfield supported by a log or schedule of dates and places worked. 
  
   WORKSHEET 
   Please note that the average working year consists of 260 available working days, excluding Saturdays and Sundays. 
   Adjustments may be made to account for various individual work schedules.  Training sessions, seminars, meetings, 
   and temporary or casual employment, although they may be outside the city, do not constitute changes in work situs 
   and are not factors in determining time worked outside the city. 
  
     ( A ) TOTAL DAYS AVAILABLE ………………………………………………………………………. ____________ 
      
     ( B ) LESS VACATION DAYS …………………………………………………………………………. ____________ 
      
     ( C ) LESS SICK DAYS ………………………………………………………………………………… ____________ 
      
     ( D ) LESS HOLIDAYS …………………………………………………………………………………. ____________ 
      
     ( E ) LESS OTHER NON-WORKING DAYS ……………………………………………………….… ____________ 
      
     ( F ) TOTAL WORKING DAYS ……………………………………………………….………………..  ____________ 
      
     ( G ) DAYS WORKED OUTSIDE THE CITY OF SPRINGFIELD (ATTACH REQUIRED LOG)..  ____________ 
      
     ( H ) DAYS WORKED INSIDE THE CITY OF SPRINGFIELD……………………………………… ____________ 
 
  COMPUTATION 
  Compute the amount to be entered as taxable city income by multiplying total income (from box 5 of W-2) by the ratio of  
  actual days worked in the City of Springfield to total working days: 
  
     ____________________ ÷ ____________________  x____________________                = $____________________ 
                   ( LINE H )            ( LINE F )              ( TOTAL INCOME )     ( TAXABLE CITY INCOME ) 
  
     INCOME TAX WITHHELD BY EMPLOYER ( FROM W-2 ) ………………………………………..  _________________ 
  
     LESS INCOME TAX DUE ( TAXABLE CITY INCOME x TAX RATE % ) …………………………. _________________ 
      
     REFUND CLAIMED ………………………………………………………………….………………….. _________________ 
                                                                                             ( to Page 1, Part B )               
RefReq (Rev.3/2023)