www.springfieldohio.gov                              INCOME TAX REFUND REQUEST  
                                                               CITY OF SPRINGFIELD, INCOME TAX DIVISION         Employer                 
                                                                                    76 EAST HIGH STREET                                Account #_______________                            
                                                                                 SPRINGFIELD, OHIO 45502                                          (FOR OFFICE USE ONLY)  
                                                          PHONE (937) 324-7357  
                                                                                                     
            THIS FORM IS FOR USE ONLY AS A SUPPORTING DOCUMENT FOR A CITY OF SPRINGFIELD 
            OR JEDD INCOME TAX RETURN. PLEASE REVIEW INSTRUCTIONS ON PAGE 2 BEFORE 
                                                                                                 COMPLETING. 
                                                                                                             
   PART A                                                                                                           
     Name                                                                                                             Social Security #                                                     
                                           ( first name, middle initial, last name )    
 
        Address                                                                                                    Phone #                                                                          
                                           ( street address, apt #, city, state, zip) 
 
        Address During Period Covered by Claim, if different from present address:   Email                                                       
                                                                                                                  
                                                                                                                      From                     _____  To              _______  
                                                     ( street address, apt #, city, state, zip)                                                                               
                                                                                                                                       Tax Rates                                                  
                                                                                                                 Springfield, 2018 and forward: 2.40%                                              
                                                                                                                 Springfield, 2017: 2.20% blended rate 
                                            TAX YEAR __________                                                  Springfield, 2016 and prior years: 2.00% 
    PART B                                                                                                       JEDD: 1.00% all years     

           Employer Name                   Location Worked                                       Taxable        Tax Due                       Amount             Refund 
                                                                                               City Income     (see tax rates above)          Withheld                Amount 
                                                                                                                                                                       
                                                           ( enter this amount on line 1 of                    ( enter this amount on line 4  ( enter this amount on  ( enter this amount on 
                                                                                                 return )         of return )                 line 6 of return )      line 15 of return ) 
         Please provide a clear and concise explanation of reason for refund:                                                                                         
           
    PART C  
  EMPLOYER VERIFICATION AND AFFIDAVIT: I hereby certify that _______________________(employee name) was 
  employed by the undersigned during the period for which said employee makes claim for refund and that ________% 
  was withheld in excess of his/her liability based on the above stated facts and calculations; and that no portion of 
  said tax withheld has been or will be refunded directly to the employee, and no adjustment in withholding remittance has 
  been or will be made.  I further declare that the information contained herein is true and correct to the best of my 
  knowledge and belief and that I am authorized to provide this information. 
   
  Authorized Name___________________________________ Title__________________________________________ 
   
  Authorized Signature________________________________ Date_________________________________________ 
   
  Name of Employer__________________________________ Phone________________________________________ 

   PAGE 2  
                                                             INSTRUCTIONS  
                                           
    1.  THIS FORM MUST BE FILED WITH A CITY OF SPRINGFIELD OR JEDD INCOME TAX RETURN.  
    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 claimants must complete Parts A and B and attach a copy of the applicable W-2(s) showing Medicare wages and 
               Springfield or JEDD withholding.  
    4.         Unless your employer has submitted a list of employees eligible for a refund, and your name is on that list, you must 
               have an authorized officer or agent of your employer complete Part C of this form.  
    5.         If you are claiming specific days worked outside this municipality, you must complete the Worksheet below and attach 
               a log or schedule of dates and places worked outside the City of Springfield.  
    6.         No refunds of ten dollars ( $10.00 ) or less will be issued.  
    7.         Refund claims will not be honored beyond three ( 3 ) years from the date the taxes were due.  
    8.         Please allow ninety ( 90 ) days for processing your complete refund claim.  
    
         ***PLEASE NOTE: INCOMPLETE CLAIMS CANNOT BE PROCESSED AND WILL BE RETURNED TO CLAIMANT***  
               
      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 APPLICABLE RATE ) ………… _________________  
                 
               REFUND CLAIMED ………………………………………………………………….…………. _________________  
                                                                                                   ( to Page 1, Part B )   

              RefReq (Rev. 1/2019)