2020 Non-Resident Employee Refund Application for                                                   64 E. Walnut St. 
                                                                                                            Westerville, OH 43081 
                       Days Worked Out of Westerville                                                       614-901-6420
                                    (Instructions on reverse side) 

Name of Applicant: 

Current Address:       __________________________________________________________ 

City/State/Zip:        __________________________________________________________ 

Social Security No.    __________________________________________________________ 

No Days out can be claimed from March 9, 2020 through December 31, 2020 per HB197 Sec 29. 

A separate form is required if you have multiple W-2 forms, for which a refund is requested.  No refunds will be issued 
without the proper documentation indicated by reason for claim. 
        Days worked outside of municipality for which the employer withheld tax. Attach a copy of your W-2 Form and the 
        additional paperwork (see instructions). In addition, your employer must complete and sign the Employer Certification 
        below.  

Salary (Box 5 on W2): $_____________        Westerville Tax Withheld: $______________ 

Annual Leave __________days: Holidays ____________days: Sick Leave ______________days: Total (1)___________ 
260 less (1) ________________ = (2) ___________ days worked 
Salary $ ________________/(2)___________________=  (3) $_____________average rate per day worked 
(2) _________________less  ________________ days worked out of Westerville = (4) _____________ days in
 Westerville (4) _______________ x (3) $________________=(5) $_______________ taxable wages for Westerville 
(5) $__________________ X 2.0% = (6) $ __________________ Westerville Tax Due

REFUND DUE $                    (Subtract (6) from tax withheld) 

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 resident or workplace municipality and the 
Internal Revenue Service. I further understand that if this refund changes my Westerville residence tax, an amended return must be filed 
before the refund will be issued.  I also understand that if I have an unpaid balance due, this refund will be applied to that balance due. 

Signed:                                 Date:                   Phone:_________________________  

                                     CERTIFICATION OF EMPLOYER 
Employer Representative’s Signature 
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. 

                                     EIN#                        Date:            Phone:  
      Name of Employer 

      Name of Authorized Personnel   Signature and Title of Authorized Personnel 

        NOTICE:        Employer Certification is required by City of Westerville 

     NON-RESIDENT EMPLOYEE REFUND APPLICATION 
             FOR DAYS WORKED OUT OF WESTERVILLE 
                                          
INSTRUCTIONS 
 
 1.  All claims must be properly signed. 
 2.  An employee who is claiming a refund of taxes withheld must list his/her employer’s 
     names and addresses and attach his/her wage statement(s) showing Westerville Tax 
     withheld (Forms W-2), telework agreement, timesheets, leave year ending paystub (ie 
     leave and earning statement), travel orders and travel vouchers, and provide additional 
     information as needed.   
 3.  The average working  year  consists of 260 days (Saturday and Sunday  are not 
     considered working days). 
 4.  Training sessions, seminars, conferences, local meetings, 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 out of the city. 
 5.  Employer’s certification MUST BE completed by authorized officer or agent. 
 6.  Attach copies of Federal forms as may be applicable. 
 7.  No refund of less than ten dollars and one cent ($10.01) will be made. 
 8.  Refund requests will not be honored beyond (3) years from the date the taxes were due. 
 9.  Refunds are issued within 90 days after the city has receipt of the correctly completed 
     Refund Application and all required documentations, or after receipt of the employer’s 
     correct W-3 reconciliation form, including all W-2 information, whichever is later.   
 
NOTE: INCOMPLETE CLAIMS CANNOT BE APPROVED AND WILL BE RETURNED TO CLAIMANT. 
 
In addition, please be advised that we will be notifying your city of residence and those Ohio cities 
shown on your itinerary that also have an income tax.   
 
No refund will be issued until ALL required tax returns have been filed and tax, penalties and/or 
interest have been paid.    
 
Overpayments will first be used to pay off any outstanding tax, penalties and/or interest owed to 
the City of Westerville.   
 
If you have any questions, call 614-901-6420 or email us at incometax@westerville.org