City of Westerville, Income Tax Division 
                              www.westerville.org/incometax
                              Claim for Refund                          / GENERAL

                                                             File Original with: City of Westerville
                                                             Income Tax Division
                                                             PO Box 130
                                                             Westerville, OH 43086-0130
                                                             (614/901-6420 – Fax 614/901-6820)

                              Tax Year 

This Form: must cover one (1) calendar year and one (1) employer only. 
Form W-2 MUST BE ATTACHED

1. Name of Applicant                                                             (Phone) 

2. Present Address (Street)                                    (City)                          (Zip) 

3. Soc. Sec No (SSN)           City of Employment 

           THE UNDERSIGNED HEREBY MAKES CLAIM FOR REFUND OF CITY INCOME TAX

4. In the amount of $         5. While in employ of

6. Work Location (Street)                                      (City) 

7. Dates of Employment

8. Resident address (if different than above) for this period

9. Reason

           AND FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER.

Date                          Signature 

                              CERTIFICATION OF EMPLOYER

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

                                                              BY: 
(Name of Employer)

Date:                  Phone:                                 TITLE: 

NOTICE: This refund may result in a balance due to your resident City and/or Federal & State tax return. PLEASE ALLOW 90 DAYS 
FOR PROCESSING OF YOUR REFUND.
(Rev 12/18)