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                               DWSM-1 Employer’s Semi-Monthly Return of City Tax Withheld 

                                                                            Tax Year                                   Period 

  EIN/FID Number:                                       W                   Choose an item.Choose an item.      Choose an item.Choose an item.    
 
  Employer Name:                                                            Should this account be inactivated?  ☐YES   ☐ No 
                                                                            IF YES 
  Address:                                                                  Please explain                                      
                                                                             
                                                                            Effective date                                      
  City:                               State:         Zip:               
                                                                             
  WITHHOLDING INFORMATION 
 
              QUALIFYING         TAX           TAX DUE       PENALTY  INTEREST               TOTAL            LESS PRIOR      NET DUE 
                WAGES           RATE                                                           DUE             PAYMENT 
                                                                                                                           
  Dublin  
  Workplace                     2% 

  Dublin                                                                                                                   
  Remote                        2% 
  Work 
                                                                                                                           
  Courtesy* 

*Courtesy is for tax due from residents working in cities with a                                                           
                                                                          TOTAL 
lower tax rate or no local tax                                  

                                                                                           **Please do not remit amounts of $10.00 or less
                         
  Complete this section ONLY if you are AMENDING a prior return              
                                 Explanation for Changes:                                                                 
                                            
                                                                                                                     Difference 
  Wages Originally Reported       Tax Originally Remitted  Corrected Wages                   Corrected Tax Due       (Tax Originally remitted 
                                                                                                                     less corrected tax due) 
                                                                                                                      
                                                                                           **Please do not remit amounts of $10.00 or less          
If difference is a negative, please indicate how you would like to handle the adjustment:   
REFUND     ☐                                   CREDIT THE ADJUSTMENT FORWARD TO NEXT QUARTER                                                  ☐ 
 
  SIGNATURE 
 
OFFICER NAME/TITLE (Please print)                                          OFFICER SIGNATURE 
 
                                                                           DATE:                                                                   
Make checks payable to:         Dublin Division of Taxation 
Mail to:                        PO Box 9062                                PHONE:                                              
                                Dublin, Ohio 43017-0962