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CCA – DIVISION OF TAXATION
P.O. Box 94520
CLEVELAND, OH 44101-4520
(216) 664-2070
http://ccatax.ci.cleveland.oh.us
Tax Year _______ APPLICATION OF REFUND
Name Social Security No.
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Name of Spouse (if filling joint)
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Current Address Apt # Phone Number

City State Zip Email

TYPE OF REFUND: Check the appropriate line.
_____ 1. UNDER LEGAL AGE. Date of Birth _________________
Attach W-2 form and proof of age (copy of your birth certificate, driver’s license or state ID). Refer to instruction booklet for specific municipality exceptions.
If you reached the minimum age to pay tax during the year, attach a letter from your employer providing a breakdown of how much was earned before and how
much was earned after your birth date. Pay stubs can be submitted in lieu of the employer’s letter. Need to complete Computation of Overpayment Worksheet.

_____ 2. DAYS WORKED OUTSIDE OF MUNICIPALITY.
Attach W-2 form, a letter from your employer (direct supervisor/manager) verifying the days worked out of the employment municipality. The employer letter must
be on company letterhead, include direct supervisor/manager signature, and contain contact information of signatory. Need to complete Log of Days Out Worksheet
and Calculation of Days Worked Outside Municipality.

_____ 3. TELEWORK/REMOTE WORKED OUTSIDE OF MUNICIPALITY.
Attach W-2 form, supporting proof of claim, which may include, but is not limited to, a telework agreement, official clock hour summaries (telework/regular hours,
benefit leave times), total office & remote days worked in/out of the employment municipality. A letter from your employer (direct supervisor/manager) verifying the
days worked out of the employment municipality. The employer letter must be on company letterhead, include direct supervisor/manager signature, and contain
contact information of signatory. Need to complete Log of Days Out Worksheet and Calculation of Days Worked Outside Municipality.

_____ 4. OVER-THE-ROAD TRUCK DRIVER.
Interstate: Truck driver regularly assigned to drive outside Ohio and/or more than one state.
Attach W-2 form, a letter from your employer (direct supervisor/manager) verifying your assigned routes. The employer letter must be on company letterhead,
include direct supervisor/manager signature, and contain contact information of signatory. Need to complete Computation of Overpayment Worksheet.
Intrastate: Truck driver regularly assigned to drive within Ohio in a local and/or regional location.
Attach W-2 form, a letter from your employer (direct supervisor/manager) verifying your assigned routes and time at principal place of employment/terminal. The
employer letter must be on company letterhead, include direct supervisor/manager signature, and contain contact information of signatory. Need to complete
Computation of Overpayment Worksheet.

_____ 5. MILITARY SPOUSE RESIDENCY RELIEF ACT.
Attach W-2 form, form DD2058, valid military spouse ID card and service member’s most recent Leave and Earnings Statement (LES). Need to complete
Computation of Overpayment Worksheet.

_____ 6. OTHER: OVER-WITHHELD TAX RATE/ WITHHELD IN ERROR.
Attach W-2 form, a letter from your employer (direct supervisor/manager) clarifying the error. Need to complete Computation of Overpayment Worksheet.

_____ 7. OVERPAYMENT OF ESTIMATE OR CREDITS
Request should be filed on the 2022 CCA Individual City Tax Form.

COMPUTATION OF OVERPAYMENT:

Line 1. Enter the amount of local wages on your Form W2; use Box 5 or 18, whichever is greater. Wages deferred for Federal and
State purposes are taxable. All Form W-2, 1099’s and statements showing reimbursements must be attached. 1. _________________________

Line 2. Enter the amount of wages that are to be excluded from tax. 2. _________________________

Line 3. Subtract the amount on Line 2 from the amount shown on Line 1. 3. _________________________

Line 4. Multiply the correct net taxable income (Line 3) by the employment municipality tax rate _______% 4. _________________________

Line 5. The amount of tax withheld by your employer. 5. _________________________

Line 6. A prior year amount taken as a credit. 6. _________________________

Line 7. Estimated payments made directly to CCA during the year. 7. _________________________

Line 8. Add Lines 5, 6 and 7. 8. _________________________

Line 9. Subtract Line 8 from Line 4. If amount is negative, you have overpaid. Worksheet and documents must be attached.
Amount $10.00 or less will not be credited or refunded. REFUND AMOUNT REQUESTED 9._________________________

I/We declare the information provided on the worksheet, to the best of my/our knowledge, is true and complete. I/We understand that if I/we have an unpaid
balance due, this refund will be applied to the balance due. I/We also understand that information regarding this request may be shared with other municipal taxing
jurisdictions, the State of Ohio, and the Internal Revenue Service.

___________________________________________ _____________________________________________ ____________________________
PRIMARY TAXPAYER SIGNATURE SOCIAL SECURITY NUMBER DATE

___________________________________________ _____________________________________________ ____________________________
SECONDARY TAXPAYER SIGNATURE (if filing joint) SOCIAL SECURITY NUMBER (if filing joint) DATE

*The processing of your refund request may be delayed up to an additional 90 days after receipt of the completed forms and/or requested
documentations.*

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CALCULATION OF DAYS WORKED OUTSIDE OF MUNICIPALITY:

1. Total work days. This is typically 260 days in a year (5 day work week X52 weeks).
Total days may decrease based on mid-year hire or departure from position. 1.________________

2. Days worked in employment municipality. 2.________________

3. Days worked outside of employment municipality. A log of days out must be
included. Complete the Log of Days Out Worksheet below. This number does not
include any benefit time used (holidays, vacation, comp/personal time, sick,
maternity/paternity or bereavement days). 3.________________

4. Total W2 wages. This is the larger number on W2 Form, Box 5 or Box 18. 4.________________

5. Non-Taxable income. Divide Line 4 by Line 1, then multiply by Line 3. 5.________________

6. Taxable Income. Subtract Line 5 from Line 4. 6.________________

7. Tax due. Multiply Line 6 by the employment municipality tax rate ________%. 7.________________

8. Amount of tax withheld. This is the number on W2 Form, Box 19. 8.________________

9. Amount of refund claimed.
Subtract Line 8 from Line 7. If amount is negative, you have overpaid. 9.________________

LOG OF DAYS OUT WORKSHEET:
List the municipalities and/or locations where you worked while outside the municipality for which tax was
withheld and the number of days worked in those municipalities and/or locations. Listing individual or
consecutive days is acceptable, but do not use “various”. Your own worksheet is acceptable if additional space
is needed.

Travel Work # of Travel Work # of
Date(s) Purpose Location Days Date(s) Purpose Location Days

TOTAL # OF DAYS WORKED OUTSIDE OF EMPLOYMENT CITY:

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