City of Canfield  
                                   104 LISBON STREET 
                                  CANFIELD, OHIO 44406-1416 
         
                                   Phone: 330-533-1101 
                                   Fax: 330-533-2668 
                                   www.canfield.gov 
                                                                                                       
Important Changes to the Tax Year 2020 Non-Resident Refund Request 
Form/Application for Municipal Income Tax Refund Related to COVID-19 
 
On March 9, 2020 Governor DeWine issues an Executive Order No. 2020-01-D Declaring a State 
of Emergency in Ohio Due to the Coronavirus Threat. Subsequently, Ohio House Bill 197 passed 
in late March 2020 containing various Covid-19 relief items. Section 29 of House Bill 197 states 
“Notwithstanding section 718.011 of the Revised Code, and for the purposes of Chapter 718. 
of the Revised Code, during the period of the emergency declared by Executive Order 2020-
01D, issued on March 9, 2020, and for thirty days after the conclusion of that period, any day 
on which an employee performs personal services at a location, including the employee's 
home, to Am. Sub. H. B. No. 197 133rd G.A. 341 which the employee is required to report for 
employment duties because of the declaration shall be deemed to be a day performing 
personal services at the employee's principal place of work”. 
 
However, subsequent to House Bill 197 the following litigation was filed against Section 29 of 
HB197: The Buckeye Institute, et al., v. Columbus City Auditor, et al, Franklin County Common 
Pleas Court Case No. 20-CV-004301. 
 
You must check the box at the top of the Non-Resident Refund Request Form if any portion of 
your application for refund is related to your working from home, or another location away 
from your regular place of work, because of COVID-19.  
 
A refund of the tax withheld for your pre-COVID-19 work municipality, while you worked from 
home or another location, may not be available until litigation over this issue is completed. See 
Buckeye Institute, et al., v. Columbus City Auditor, et al, Franklin County Common Pleas Court 
Case No. 20-CV-004301. (Please note: If this case is not dismissed, the case is not expected to 
be heard until July 7, 2021 if not disposed of earlier by other motions. Also, both parties are 
expected to appeal the decision.) 
 
The City of Canfield will hold your request for refund in a suspended status until this litigation is 
concluded. Should the conclusion of this litigation determine that a refund is allowed, your 
request for refund will be processed at that time. Should the conclusion of the litigation 
determine that a refund is not allowed, you will receive a notice that a refund is not available to 
you. 

                                NON-RESIDENT REFUND 

                                                REQUEST FORM

      First name                     La  st name                           Your social security number            Tax year of claim 

      Current home address (number and street)            Apt #           Phone number            Email Address 

      City, state, and ZIP code 
                                                                                         Check here if you worked outside 
                                                                                         of your normal place of work in 
                                                                                         2020 due to COVID-19. 

     1. Were you ever a resident of the Municipality of Canfield? ______   If yes, give dates: __________________

      Prior Canfield Address ___________________________________________________________________

                      THE UNDERSIGNED HEREBY MAKES CLAIM FOR REFUND OF INCOME TAX  
                                     FROM THE MUNICIPALITY OF CANFIELD, OHIO. 
     2. For tax year of ____________ (one per form)      6. In the amount of $ ______________

     3. While employed by ______________________________________________________________________

     4. Complete address of work location __________________________________________________________

     5. For the period of (dates) __________________________________________________________________

     6. Resident address for this period ____________________________________________________________

     7. Reason for request (explain fully) ___________________________________________________________

         AND FURTHER STATES THAT SAID REFUND HAS NOT BEEN RECEIVED BY HIM/HER.
   Sworn to and subscribed before me this 
  __________ day of _________________, __________

  ____________________________________________ 
  Signature Officer Administering Oath 
  ___________________________________________              __________________________________________ 
  Title                                                    Signature Taxpayer Claiming Refund 
                                         CERTIFICATION OF EMPLOYER 

I hereby certify that the above employee was employed by the undersigned during the period for which said employee 
makes claim for refund and that during said period $__________ was withheld from the earnings paid said employee; 
that the total amount of $__________ was withheld for the year ________; that said employee was not, during the period 
claimed above, working inside corporate limits of the Municipality of Canfield, Ohio and that no portion of said tax withheld 
has been or will be refunded to said employee; and that no adjustment has been or will be made in remitting taxes 
withheld to the Municipality of Canfield, Ohio. 

  _____________________________________________    By: _______________________________________  
  (Name of Employer)  
  Employer's Federal ID:__________________       _______ _ ____________________________     ___________
                                                           (Title)                                      (Date)

INSTRUCTIONS FOR COMPLETING REFUND FORM 

           THE MUNICIPALITY OF CANFIELD, OHIO 

This form is for a nonresident who performs no service within the corporate limits of the Municipality 
   of Canfield, Ohio and whose employer withheld the City Of Canfield Income Tax in error. 

Refunds will not be issued during the same year as the tax was erroneously withheld. 

   IF ALL INSTRUCTIONS ARE NOT FOLLOWED, REFUND WILL 
   NOT BE APPROVED AND CLAIM FORM WILL BE RETURNED. 

A. TAXPAYER

   The top portion of this form and numbered section is to be completed by the taxpayer
   requesting the refund.
   Please make sure to:

    Check mark the box only if the refund request is for working from home due to Covid-19.
     (Your refund request will be held in suspended status until litigation is concluded (see notice on
     cover sheet of this form). Please make sure to follow the case for updates on when refunds or
     notices of ineligibility will begin being processed.

    Fill in the year for which claim is being filed.

    Attach W-2 form (copy is acceptable) and any substantiating information and forms.

    Explain fully and concisely why the City of Canfield Income Tax should be refunded.
     Attach any pertinent information or explanations if space provided is not sufficient.

   IMPORTANT: If under 18 please give date of birth. Additional proof of age may be required. 

B. NOTARIZE

   This claim must set forth in detail and under oath each ground upon which it is made, and facts
   sufficient to apprise the Income Tax Division of the exact basis thereof.

C. EMPLOYER CERTIFICATION

   Employer or authorized Officer or Agent must complete certification of employer.