Who can use the Nonresident Income Tax Refund Request Form?

Individuals claiming a refund of Lebanon income tax withheld in excess of their liability can use this form. A separate form is required for each employer and tax year.

What must I include with my refund request?

The form requires clear and complete W-2 forms and employer certification. If requesting a refund for days worked outside Lebanon, complete the attached workday schedule; otherwise, provide a written explanation of how taxable income was calculated.

How do I submit the refund request?

The form lists the Income Tax Department at 50 S. Broadway, Lebanon, Ohio 45036, along with incometax@lebanonohio.gov and fax (513) 228-3902.

Do I need a notary for the Nonresident Income Tax Refund Request Form?

No. The claimant and employer sign their certifications, and the form does not identify a notarized attachment.

Lebanon, OH · Warren County

No notary required

Nonresident Income Tax Refund Request Form

Nonresidents use this form to request a refund of Lebanon income tax withheld in excess of their tax liability for a specific employer and tax year.

What this form is

This form lets a nonresident request a refund of Lebanon income tax withheld in excess of their liability. Complete a separate form for each employer and tax year; the form says requests must be made within three years of payment or the return due date. It asks for claimant, employer, income, withholding, and workday details, and requires employer certification and clear W-2 forms.

Who needs it

A nonresident seeking a refund of Lebanon income tax withheld beyond their liability should complete a separate request for each employer and tax year.

How to submit it

The form lists the Income Tax Department at 50 S. Broadway, Lebanon, Ohio 45036, and provides [email protected] and fax (513) 228-3902.

About notarization

This document is signed and dated without a notary; the claimant and employer sign their respective certifications, and the form does not identify a notarized attachment.

How to submit this form

1
Download The Form
Download the Nonresident Income Tax Refund Request Form.
2
Complete The Form
Enter claimant, employer, tax-year, income, withholding, and workday information. Complete a separate form for each employer and tax year.
3
Gather Required Attachments
Attach clear and complete W-2 forms and the workday schedule if claiming a refund for days worked outside Lebanon.
4
Get Employer Certification
Have the employer complete and sign Part 3, which the form says must be completed in all instances.
5
Submit To The Income Tax Department
Use the Income Tax Department contact details printed on the form: 50 S. Broadway, Lebanon, Ohio 45036; [email protected]; fax (513) 228-3902.

Frequently asked questions

Who can use the Nonresident Income Tax Refund Request Form?: Individuals claiming a refund of Lebanon income tax withheld in excess of their liability can use this form. A separate form is required for each employer and tax year.
What must I include with my refund request?: The form requires clear and complete W-2 forms and employer certification. If requesting a refund for days worked outside Lebanon, complete the attached workday schedule; otherwise, provide a written explanation of how taxable income was calculated.
How do I submit the refund request?: The form lists the Income Tax Department at 50 S. Broadway, Lebanon, Ohio 45036, along with [email protected] and fax (513) 228-3902.
Do I need a notary for the Nonresident Income Tax Refund Request Form?: No. The claimant and employer sign their certifications, and the form does not identify a notarized attachment.

Need something notarized?

This Nonresident Income Tax Refund Request Form doesn’t need a notary — but if you have another Lebanon form that does, a commissioned online notary can help.