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Calculation of Days Worked Outside of Wooster
1 Total workdays available. If you normally work a 5 day work week and you worked for your employer for the
entire year, enter 260 (52 weeks times 5 days). Otherwise, enter the number of days you normally worked in a week
times the number of weeks worked (cannot exceed 260). 1
2 Days not worked. Enter # of days included on line 1 that you did not work due to holidays, personal days, sick
days, and vacation days. 2
3 Total days actually worked. Subtract line 2 from line 1 3
4 Days worked out of town. A log of days out, destination, and reason for travel must be included (see below).
If you worked more than 12 days in another municipality (city or village) that has an income tax, attach a copy of the
tax return filed with that municipality. 4
5 Days worked in the municipality for which tax was withheld. Subtract line 4 from line 3. 5
6 Total days taxable to the City of Wooster. Add line 2 & line 5 6
7 Percentage of wages earned in the municipality. Divide line 6 by line 1. 7
8 Total municipal taxable wages. Enter the larger of Box 5 or 18 from your W-2. 8
9 Wages taxable to municipality for which tax was withheld. Multiply line 7 by line 8. 9
10 Wages not taxable to the municipality for the which tax was withheld. Subtract line 9 from
line 8. 10
11 Amount of over withholding claimed. Multiply line 10 by 1.5% (.015). 11
Log of Days Out
List the names of the municipalities/locations where you worked while traveling, the reason for your travel, and
the number of days worked at your travel destination. Your own worksheet is acceptable. Use additional paper if
necessary.
Work Location Reason #Days
1
2
3
4
5
6
7
8
9
10
Total number of days worked out of Wooster
Employer Certification
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 referenced 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.
In addition, the undersigned employer representative verifies that no portion of the over-withheld tax has been or will be refunded directly to
the employee by the employer, and that no adjustments to the employer's withholding account related to this claim have been or will be
made.
Representatives' Signature Title Date
Print Representative's Name Phone Number
Taxpayer's Signature
Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct and
complete. I understand that this information may be released to the tax administrator of the municipality of residence or the Internal
Revenue Service. I further understand that if I have a balance due for prior year(s), this refund will be applied to that balance before
issuance.
Taxpayer's Signature Date
Spouse's Signature Date
Preparer's Signature Date Phone Number
Do you authorize your preparer to contact us regarding this return? Yes No
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