City of Dublin 
                                                Division of Taxation 
                                                P.O. Box 9062 
                                                Dublin, Ohio 4301 -07 962 
                                                Telephone (614) 410-4460 
                                                Toll Free (888) 490-8154 
                                                Fax (614) 923-5542 
                                                www.dublin.oh.us 
 
TAX REFUND REQUEST FOR INDIVIDUALS UNDER AGE 18  
 
TAX YEAR: ________ 
 
Please Print 
NAME: _________________________________ SOCIAL SECURITY: _____________________ 
 
PRESENT ADDRESS: ___________________________________________________________ 
 
CITY, STATE AND ZIP CODE: ____________________________________________________ 
 
TELEPHONE NO. ________________________________ 
 
TOTAL DUBLIN TAX WITHHELD  $ ________________ 
 
REFUND AMOUNT REQUESTED $__________________ 
 
COMPANY NAME: _____________________________________________________________ 
 
ADDRESS WHERE WORKED: __________________________________________________ 
 
PROOF OF BIRTH MUST ACCOMPANY THIS REQUEST FOR A REFUND. PROOF  
SHOULD BE A LEGIBLE COPY OF BIRTH CERTIFICATE OR DRIVER’S LICENSE. 
 
W-2 FORM MUST BE ATTACHED. 
 
SIGNATURE: ____________________________________ DATE: ______________________ 
 
NOTICE: 
PLEASE ALLOW 90 DAYS FOR PROCESSING OF YOUR REFUND REQUEST