Form ORR - File With: 
                                                                                CITY OF FAIRFIELD                                                        INCOME TAX 
  CITY            OF   FAIRFIELD 
  INCOME TAX                   DEPARTMENT 
  701 Wessel Drive                                                                   REFUND REQUEST FORM
  Fairfield,  Ohio 45014 

  PART I                                                 □  Check here if you are a remote worker/telecommuter (Complete Sections A, B & C and Schedule 1)
                                                         Check at least one:         □ Non-Resident       □Under Age 18                                                 
  TO BE USED ONLY BY PERSONS UNDER AGE 18 AND FULL-YEAR, NON-RESIDENT INDIVIDUALS WITH W-2 WAGE INCOME

  A. NAME  AND                                 CURRENT ADDRESS:                                                                                                                                                                                       For  the Calendar Year 
                                                                                                                                                                                                                                                      Refund  Claimed  $ 

                                                                                                                                                                                                                         Social Security                       No. 

    Address  during  claim                            period:     

    Employer's  Name   

       Work Address (may not be W-2 address) 

  B.           COMPUTATIONOF                            O VER        P  AYM NE  T:

               1. Inco        me aEer             n d (Typically Box 18 of form W-2)                                       . . . . . . . . . . . . . . . . . . . $
               2. FairfieldTax Withhedl                   (atta   chc op oy   formf W2 .).                                                               . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
               3. Ear  nings S            ubject   t  oFairfieldTax (from below)  . .                                   . . . . . . . . . . . . . . . $
               4. Fairfield Tax (1.5%   of line                                                                                                    3 .). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
               5. O eva       rp yment Clai           me  d (line   2minus line                                                                                                                  4 .). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

               Please note that in accordance with Ohio Revised Code Section 718.19, refunds requested of $10.00 or less cannot be issued. 

C. BASIS FOR                          REFUND:            Give brief but complete  explanation.  If applicable, complete days out computation below.

        REMOTE WORKERS PROCEED DIRECTLY TO SCHEDULE 1. 

D. CALCULATION of DAYS WORKED OUTSIDE THE CITY OF                                                                                                            FAIRFIELD  :

                              6.       Total days available                  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
                              7.       Less:            Vacation days  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
                                                        Sick days   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
                                                        Holiday days   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                                                                                                              (         ) 
                              8.    Total Available Working Days  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 
                              9.   Less:  Days worked outside Fairfield (attach schedule)  .  .  .  .  .  .  .  .  .  .                                                                                                                               (         ) 
                              10.  Days worked in the City of Fairfield   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 

                       (Line 10 days) 
                                                                                X  $                                                                              =  $ 
                       (Line 8 days)                                              Total Wages (Line 1)                                                            Adjusted Wages Subject to Fairfield Tax 
                                                                                                                                                                  (Enter on Line 3) 

                                                                                                          Page 1 

PART II - EMPLO YER'S CERTIFICATION (Read Carefully) – Not required for persons under age 18  or remote workers.  
            (Remote workers and their employers should sign Schedule 1) 

Name of Employee                   _____________________________________________________________________________ 
Home Address on Record             ____________________________________________________________ 
Employee’s Employment Dates  ______________________      _________________________________ 
                                   Date of Hire              Date of Separation (enter date or continues) 

The undersigned employer 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 as calculated above; that the above named employee was employed during the period 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 is true and accurate. 
The undersigned employer representative also certifies that for any portion of days listed as working at home or another location due to COVID-19, the 
employee was working and not on paid leave.  

    EMPLOYER NAME:  ___________________________________________________________          FEI #:  ___________________________________________ 
    REPRESENTATIVE SIGNATURE:  __________________________________________________  DATE:  ___________________________________________ 
    REPRESENTATIVE PRINTED NAME:  _______________________________________________ 
    TITLE:    __________________________________________________________________________ TELEPHONE:  ____________________________________ 

PART III – TAXPAYER’S SIGNATURE - Required 

In accordance with ORC 718.13; the City of   Fairfield will furnish your city of residence and any employment city a copy of this refund
document.

Under penalties of perjury, I declare that this claim, to the best of my knowledge and belief, is true, correct and complete.  I understand that 
this information may be released to the tax administrator of the resident or other workplace municipality and the Internal Revenue Service.  

SIGNED:                                                                                DATE: 
          (Taxpayer's Signatur )e  

                                                                             Page 2 

                                         REFUND REQUEST GENERAL INSTRUCTIONS 

   This form is to be used only by persons under the age of 18 and/or full-year, non-resident    
 individuals claiming a refund of Fairfield income tax withheld in excess of their actual 
 liability. 

   Please attach a copy of your form W-2.  If you are under the age of 18, you must provide  
 verification of your age (driver’s license, certificate of birth or passport). 
 PART 1:      If any portion of your refund claim is due to days working at home or another location away from 
              your regular place of work due, you must check the box for remote worker.   

 SECTION A:     List name, current mailing address, calendar year of refund claim, amount of refund and your social 
             security number.   List       address during claim period if different from your current address.  List your 
               employer’s name and your physical work address. 

 SECTION B:  1.    Enter total wages subjected to         Fairfield tax by your employer.  Typically this will be reported in Box  
                   18 of your form W-2.
             2.    Enter the Fairfield tax withheld as shown in Box 19 of your form W-2.
             3.    Enter the wages which should have been subject to Fairfield tax.  Persons under the age of 18 for 
                   entire year should enter zero.  If you turned age 18 during the year, attach computation showing 
                   wages earned prior to and after turning 18.  All other filers should complete the days worked outside 
                   Fairfield computation from Section D.
             4.    Line 3 x  .5% (0.0 5).1 1
             5.    Enter the difference between Line 2 and Line 4.  Amount of refund requested must exceed $10.00.

 SECTION C:     Basis for refund:          A brief but complete explanation by the taxpayer is required regarding  
             the reason for the overpayment to be refunded.  If duties require travel, you must provide a 
             list of dates worked out of Fairfield. Your schedule must include the physical address where services  
            were performed and the reason for your travel.  

Remote workers proceed directly to Schedule 1. 

 SECTION D:     6.  If you normally work a 5-day workweek and you worked for your employer for the entire year,
                 enter 260 (52 weeks x 5 days.)  Otherwise, enter the number of days you normally worked in a 
                 week times the number of weeks worked. 
                7. Enter your vacation, sick and holiday days.
                8. Enter line 6 less line 7.
                9. Enter the number of days worked outside Fairfield from your attached travel log.  See Section C 
                   for the schedule requirements.  Do not include any day at home due to COVID-19 that was 
                   considered paid leave and not a full work day.
            10.    Enter line 8 less line 9.  Compute the amount to be entered as taxable wages on Line 3 by 
                   multiplying the total compensation by the ratio of days worked in the City of Fairfield over the 
                   total available working days.

 PART II:    The employer must complete all requested information and provide a signature.  The employer 
            certification is not required for taxpayers under the age of 18 or persons claiming remote worker. 

 PART III:    Your signature is required in order to validate this request. 

                                                                       Page 3 

                                                                                               SCHEDULE 1 

      NAME   ________________________________               TAX YEAR________ 

A refund of tax withheld is requested as I am a remote worker. My principal 
place of work is _____________________________________________________. 
                                    (HOME ADDRESS) 

                        DAYS WORKED INSIDE CITY OF FAIRFIELD 
                           DAYS AVAILABLE COMPUTATION 

                                                   EXAMPLE   YOUR CALCULATIONS 

TOTAL DAYS AVAILABLE                               260 
(365 minus weekends not worked) 
Salaried individuals enter 26 0
LESS:  HOLIDAY DAYS                                (10) 

       VACATION DAYS                               (10) 

       SICK DAYS                                   (5) 

TOTAL AVAILABLE WORKING DAYS                       23 5

DAYS WORKED INSIDE CITY OF FAIRFIELD 
(Complete following schedules) 
DAYS WORKED OUTSIDE FAIRFIELD  
(Total available days less Fairfield days) 

Under penalties of perjury, I declare that this claim, to the best of my knowledge and belief, is true, correct and complete. I 
understand that this information may be released to the tax administrator of my resident city. 
______________________________________________              __________________ 
Taxpayer Signature                                           Date 

I agree that the employee worked as indicated on the following schedules and that no withholding taxes have been refunded 
to the employee.  
______________________________________________              __________________ 
Employer’s Signature                                        Date 
______________________________________________              __________________ 
Employer’s Printed Name                                         Telephone Number 
______________________________________________ 
Title 

                                               SCHEDULE 1

        DAYS WORKED INSIDE THE CITY OF FAIRFIELD 

   WORK LOCATION (S)    WORK LOCATION (S)    WORK LOCATION (S) 
        JANUARY               FEBRUARY             MARCH 
DATE                 DATE                 DATE 
1                    1                    1 
2                    2                    2 
3                    3                    3 
4                    4                    4 
5                    5                    5 
6                    6                    6 
7                    7                    7 
8                    8                    8 
9                    9                    9 
10                   10                   10 
11                   11                   11 
12                   12                   12 
13                   13                   13 
14                   14                   14 
15                   15                   15 
16                   16                   16 
17                   17                   17 
18                   18                   18 
19                   19                   19 
20                   20                   20 
21                   21                   21 
22                   22                   22 
23                   23                   23 
24                   24                   24 
25                   25                   25 
26                   26                   26 
27                   27                   27 
28                   28                   28 
29                                        29 
30                                        30 
31                                        31 

JANUARY               FEBRUARY             MARCH 
DAYS IN  ________     DAYS IN   ________   DAYS IN  ________ 

                                                     SCHEDULE 1 

              DAYS WORKED INSIDE THE CITY OF FAIRFIELD 

   WORK LOCATION (S)    WORK LOCATION (S)       WORK LOCATION (S) 
        APRIL                 MAY                        JUNE 
DATE                 DATE                    DATE 
1                    1                       1 
2                    2                       2 
3                    3                       3 
4                    4                       4 
5                    5                       5 
6                    6                       6 
7                    7                       7 
8                    8                       8 
9                    9                       9 
10                   10                      10 
11                   11                      11 
12                   12                      12 
13                   13                      13 
14                   14                      14 
15                   15                      15 
16                   16                      16 
17                   17                      17 
18                   18                      18 
19                   19                      19 
20                   20                      20 
21                   21                      21 
22                   22                      22 
23                   23                      23 
24                   24                      24 
25                   25                      25 
26                   26                      26 
27                   27                      27 
28                   28                      28 
29                   29                      29 
30                   30                      30 
                     31 

APRIL                 MAY                       JUNE 
DAYS IN  ________     DAYS IN      ________      DAYS IN       ________ 

                                                 SCHEDULE 1 

             DAYS WORKED INSIDE THE CITY OF FAIRFIELD 

     WORK LOCATION (S)    WORK LOCATION (S)    WORK LOCATION (S) 
        JULY                   AUGUST            SEPTEMBER 
DATE                   DATE                 DATE 
1                      1                    1 
2                      2                    2 
3                      3                    3 
4                      4                    4 
5                      5                    5 
6                      6                    6 
7                      7                    7 
8                      8                    8 
9                      9                    9 
10                     10                   10 
11                     11                   11 
12                     12                   12 
13                     13                   13 
14                     14                   14 
15                     15                   15 
16                     16                   16 
17                     17                   17 
18                     18                   18 
19                     19                   19 
20                     20                   20 
21                     21                   21 
22                     22                   22 
23                     23                   23 
24                     24                   24 
25                     25                   25 
26                     26                   26 
27                     27                   27 
28                     28                   28 
29                     29                   29 
30                     30                   30 
31                     31 

JULY                    AUGUST               SEPTEMBER 
DAYS IN  ________    DAYS IN    ________     DAYS IN    ________ 

                                               SCHEDULE 1 
                DAYS WORKED INSIDE THE CITY OF FAIRFIELD 

   WORK LOCATION (S)    WORK LOCATION (S)             WORK LOCATION (S) 
        OCTOBER           NOVEMBER                      DECEMBER 
DATE                 DATE                      DATE 
1                    1                         1 
2                    2                         2 
3                    3                         3 
4                    4                         4 
5                    5                         5 
6                    6                         6 
7                    7                         7 
8                    8                         8 
9                    9                         9 
10                   10                        10 
11                   11                        11 
12                   12                        12 
13                   13                        13 
14                   14                        14 
15                   15                        15 
16                   16                        16 
17                   17                        17 
18                   18                        18 
19                   19                        19 
20                   20                        20 
21                   21                        21 
22                   22                        22 
23                   23                        23 
24                   24                        24 
25                   25                        25 
26                   26                        26 
27                   27                        27 
28                   28                        28 
29                   29                        29 
30                   30                        30 
31                                             31 

OCTOBER                    NOVEMBER             DECEMBER 
DAYS IN  ________      DAYS IN        ________  DAYS IN         ________ 

                     TOTAL DAYS WORKED INSIDE CITY OF FAIRFIELD  ____________