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Check here if you worked outside of
your normal workplace in response to
Income Tax Division COVID-19. See checkbox no. 2 below.
100 Lockville Road
Pickerington, Ohio 43147
Application for Municipal Income Tax Refund
This form can cover one calendar year and one employer only. No refunds will be issued without proper documentation.
Social Security Number Tax Year of Claim
First Name and Middle Initial Last Name
Current Address (number and street) Apt #
City and State Zip Code
Refund in the amount of $_________________ Resident Address for these Dates: ______________________________________________
Employer Name: ___________________________________________ Employment Dates from: ____/____/_______ to: ____/____/_______
Reason for Claim
1. Age Exemption : Date of Birth ____/____/_______ Attach a copy of your W-2 form and provide proof of birthdate (birth certificate, driver’s
license, etc.). If you were underage for only part of the year, you must either: (1) have your employer sign the Employer Certification below;
or (2) attach a copy of your pay stub for the pay period in which you turned 18.
2. Days Worked from Home If: your employer withheld Pickerington income tax for days that you were working from home outside of
Pickerington, attach a copy of your W-2 Form and provide a log of days worked outside of the city. Your employer must complete
the Employer Certification section below. If any of the days worked from home were in response to the COVID-19 pandemic, please check
the box at the top right of this page.
3. Military Spouse Residency Relief Act :Attach copies of W-2 Form, Form DD 2058, valid military spouse ID card, and service member’s most
recent LES.
4. Lived and worked outside Pickerington City limits :If you did not live or work in Pickerington at any time during the year referenced above,
attach a copy of your W-2 Form. Your employer must complete the Employer Certification below.
5. Other (Indicate Reason) : Attach W-2 Form and other applicable documentation. Your employer must complete the Employer Certification
below. Reason (Explain fully or attach work schedule/locations): ________________________________________________________________________
______________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________ ___
By signing below, I confirm that I have not previously received any of the refund claimed above. I also understand that this information may be released
to the tax administration of the city of residence, the State Tax Department and/or the Internal Revenue Service.
SIGNATURE: DATE:_____________________________________
Employer Certification
The undersigned 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; that the employee was employed during the time 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 with respect to time worked in
the municipality withheld 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.
_____________ ____ _________________
Name of Employer Signature of Representative Date Phone Number
_____ ______________
Print Representative’s Name and Title Explanation of Reason for Refund (e.g. ‘taxpayer works from home 4 days’)
NOTICE: No refund will be issued for amounts less than $10.01.
This refund may result in an amendment to Federal, State, or other city tax returns.
Refunds over $10.00 are reported to the IRS.
Please allow up to 90 days for processing of your refund request.
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