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INSTRUCTIONS
1. THIS FORM IS INTENDED ONLY FOR THE USE OF NON-SPRINGFIELD RESIDENTS AND/OR THOSE UNDER 18
YEARS OF AGE.
2. Do not combine refund claims for more than one employer. A separate form must be completed for each employer
for which you are claiming a refund of income tax withheld.
3. All claims must be properly signed by the claimant.
4. All claimants must complete Parts A and B and attach copy of W-2 showing Springfield withholding and box 5
Medicare wages.
5. Unless you are under the age of 18, or unless your employer has submitted a list of employees who are eligible for
a refund, you must have an authorized officer or agent of your employer complete Part C of this form.
6. Refund claims for persons under 18 years of age must include verification of the exact birth date of claimant, i.e.,
photo copy of birth certificate, driver’s license, or state issued identification card.
7. You must file a City of Springfield Income Tax Return in place of this form if: a) you were a resident of the City of
Springfield for any part of the tax year in question; or b)you are a Springfield resident whose 18 birthdaythoccurred
during the tax year in question. For these situations, additional documentation will be required, including but not
limited to copies of pay stubs, verification of move dates, proof of date of birth, and/or copies of Federal Schedules C
and/or E.
8. You must file a City of Springfield Income Tax Return in addition to this form if: a) you were a part year
Springfield resident and worked in another city; or b)you owned rental property located inside the City of Springfield or
you were self-employed and conducted business inside the City of Springfield during the tax year in question.
9. No refunds of less than $10.01 will be issued.
10. Refund claims will not be honored beyond three (3) years from the date the taxes were due or paid, whichever is later.
11. Please allow ninety (90) days for processing your completed refund claim.
***PLEASE NOTE: INCOMPLETE CLAIMS CANNOT BE PROCESSED AND WILL BE RETURNED TO CLAIMANT***
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The following worksheet is to be completed only by those claiming specific days worked outside the City of
Springfield supported by a log or schedule of dates and places worked.
WORKSHEET
Please note that the average working year consists of 260 available working days, excluding Saturdays and Sundays.
Adjustments may be made to account for various individual work schedules. Training sessions, seminars, meetings,
and temporary or casual employment, although they may be outside the city, do not constitute changes in work situs
and are not factors in determining time worked outside the city.
( A ) TOTAL DAYS AVAILABLE ………………………………………………………………………. ____________
( B ) LESS VACATION DAYS …………………………………………………………………………. ____________
( C ) LESS SICK DAYS ………………………………………………………………………………… ____________
( D ) LESS HOLIDAYS …………………………………………………………………………………. ____________
( E ) LESS OTHER NON-WORKING DAYS ……………………………………………………….… ____________
( F ) TOTAL WORKING DAYS ……………………………………………………….……………….. ____________
( G ) DAYS WORKED OUTSIDE THE CITY OF SPRINGFIELD (ATTACH REQUIRED LOG).. ____________
( H ) DAYS WORKED INSIDE THE CITY OF SPRINGFIELD……………………………………… ____________
COMPUTATION
Compute the amount to be entered as taxable city income by multiplying total income (from box 5 of W-2) by the ratio of
actual days worked in the City of Springfield to total working days:
____________________ ÷ ____________________ x____________________ = $____________________
( LINE H ) ( LINE F ) ( TOTAL INCOME ) ( TAXABLE CITY INCOME )
INCOME TAX WITHHELD BY EMPLOYER ( FROM W-2 ) ……………………………………….. _________________
LESS INCOME TAX DUE ( TAXABLE CITY INCOME x TAX RATE % ) …………………………. _________________
REFUND CLAIMED ………………………………………………………………….………………….. _________________
( to Page 1, Part B )
RefReq (Rev.3/2023)
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