Application For Employee Refund Of Occupational Taxes Withheld - Louisville/jefferson County Metro Revenue Commission Page 2
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1
2PART IV: EXPLANATION FOR REFUND
th
Quarters Involved in Overpayment
1st
2nd
3rd
4
Jan-March
April-June
July-Sept
Oct-Dec
(Check applicable quarters)
Check appropriate explanation below:
Occupational taxes withheld from wages of employee while working outside Louisville Metro, Kentucky. (Complete Part III and
provide signature in Part V)
1.
School Board tax withheld from wages of employee who was a non-resident of Louisville Metro, Kentucky during all or part of tax
year. (Complete Part V)
2.
Occupational taxes withheld at a higher rate than 2.2%.
3.
Occupational taxes withheld at a higher rate than .75% if a domestic worker or minister. (If minister, complete Part VI)
4.
Domestic worker or minister exempt from .75% tax rate (Must be a non-resident of Louisville Metro, Kentucky)
5.
Other: (Must provide detailed explanation) ___________________________________________________________________
6.
If you are requesting a refund as a result of one of the items described on Lines 2 - 6, please enter the amount of refund
you are requesting: $______________.
PART V: NON-RESIDENCY STATEMENT- Must be completed if claiming refund as a non-resident of Louisville
Metro, Kentucky
I hereby certify that my residence is:
(Street Address)
City/County/State/Zip:
Since:
(Date)
PART VI: MINISTER’S STATEMENT - (Must be completed if claiming refund at minister’s tax rate)
I hereby certify that I have been ordained since _________________ (Date)
PART VII: SIGNATURE CERTIFICATIONS
EMPLOYEE’S CERTIFICATION
I hereby certify that the information provided above is true and correct.
Employee’s Signature: __________________________________________________________
Date: __________
(Must be notarized)
EMPLOYER’S CERTIFICATION
I hereby certify that the information provided above is true and correct.
Employer’s Authorized Signature: __________________________________________________ Date: __________
Subscribed and sworn to before me this _____ day of ____________________, 20_____, by
_______________________________________________________.
My Commission expires: ____________________.
___________________________________________
Notary Public, State at Large, ___________________
NOTICE: If an employer did not remit the taxes and/or quarterly employee withholding tax return for the
period(s) of the refund, the Louisville/Jefferson County Metro Revenue Commission will notify you that no
refund will be issued due to your employer’s failure to remit payment of taxes and/or failure to file the quarterly
.
employee withholding tax return. Contact your employer to resolve this problem
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