City of Fairfield
                                                                    Income Tax Division 
                            Non-Resident Refund Request             701 Wessel Dr 
                                         2023                       Fairfield, OH 45014 
                                                                    www.fairfield-city.org
                                                                    Phone: 513-867-5327 
                                                                    Fax: 513-867-5333
                                                                    Email: income.tax@fairfield-city.org

Dear Taxpayer,

The Non-Resident Refund Request should be used if your request is the result 
of days worked outside of Fairfield.  You must complete the form as well as an 
itinerary for the entire calendar year. The days worked in Fairfield, holidays, 
sick days, and vacation days must be verified for accuracy by your employer. 
This person must have legal authority to sign on behalf of the company and 
have direct knowledge of your work schedule. 

The completed form, itinerary, and W-2 showing Fairfield withholdings can be 
submitted to our office for review at the mailing address, email, orfax number 
listed above.

In addition, please be advised that we will be notifying your resident city, if 
applicable. Since you are receiving a refund of taxes withheld for your base 
city of employment, the city of residence may elect to pursue recovery of these 
dollars.

Sincerely, 

City of Fairfield
Income Tax Division 

                                                  For Tax Year 202 3

                                   NON-RESIDENT REFUND REQUEST
                                                  For Days Worked Out of Fairfield  
                                                  Or Taxes Over Withheld by Employer 

☐During the year 202 ,3  my employment with __________________________________________ located in the City of
Fairfield, required me to perform services both inside and outside the corporate boundaries of the City as follows:

    Total Days Paid 52 Weeks @ 5 Days per Week or 260 Working Days: 
                         (or dates of employment -beginning ________________ thru ________________ ) 

                               Number of Working Days Outside Fairfield ____________  

                               Number of Paid Holidays, Sick Days, and Vacation Days _______________

                               Number of Working Days In Fairfield____________ 

                                                              OR

☐During the year 2023, my employer ______________________________________ over withheld Fairfield city
income taxes for the following reason:
________________________________________________________________________________________________

Under penalties of perjury I hereby certify that the information provided herein is true, correct and complete to the best 
of my knowledge and belief.  

Print Employee’s Name                                               Date  

Employee’s Signature                                                Social Security Number 

Employee’s Street Address                                          Daytime Phone Number 

Employee’s City, State, Zip                                          City of Residence 

      You must attacha copy ofyourW-2                showing Fairfield wages and Fairfield income taxes withheld. 

We will calculate and issue a refund (if any) based on the information provided. You will be 

                                   notified of your anticipated refund amount via USPS.

~ ~ ~ ~ ~ ~ ~ ~ ~ EMPLOYER’ S VERIFICATION ~ ~ ~ ~ ~ ~ ~ ~ ~ 

The number of days work in Fairfield shown above reflect actual working days at principal place of work. Additionally, 
no refund of withheld taxes have been paid to employee. 

Employer’s / Manager’s Signature                                    Date 

Print Employer’s / Manager’s Name                                   Title 

Employer’s / Manager’s Phone Number and Extension 

                                   Please mail, email, or fax completed form and copy of W-2 to:
                                   Income Tax Division - 701 Wessel Drive, Fairfield, OH 45014 
                                                  income.tax@fairfield-city.org 
                                                            513-867-5333

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