Form B - Annual Claim - Application For Employee Refund Of Occupational Taxes Paid

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CITY OF JEFFERSONTOWN, KY

FORM “B” (Annual claim)

Application for Employee refund of Occupational Taxes paid

Phone: (502) 267-8333

Fax: (502) 267-0547

SECTION 1 - EMPLOYEE – EMPLOYER INFORMATION

February 4, 2013

2012

APPLICATION DATE:

_________________

REQUEST FOR YEAR OF:

_________________

EMPLOYEE NAME:

_______________________________________________________________________

MAILING ADDRESS:

_______________________________________________________________________

POSITION:

_______________________________________________________________________

------------------------------------------------------------------------------------------------------------------------------------------------------------------

EMPLOYER NAME:

_______________________________________________________________________

STREET ADDRESS:

_______________________________________________________________________

EMPLOYER FED. ID. #

____________________________

PHONE: __________________________

DESCRIPTION OF BUSINESS: _________________________________________________________________________________

SECTION II – REFUND APPLICATION WORKSHEET

Line 1

________________________

Total Gross Wages (including deferred compensation)