Form B - Annual Claim - Application For Employee Refund Of Occupational Taxes Paid Page 2
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3SECTION III – EXPLANATION FOR REFUND & EMPLOYEE STATEMENT
I hereby certify that the above information on page one (1) is complete and accurate to the best of my ability. I further
state that the percentage of time worked (Line 4) In the City of Jeffersontown is accurate. I have attached written proof
of such claim in the form of the following:
•
Mileage logs or schedule of total hours worked inside and outside the City of Jeffersontown
•
Written Employer statement of explanation concerning Employee time worked inside and outside the City of
Jeffersontown. (Any additional information and/or written explanation relating to employee request for
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refund of occupational taxes must be signed by authorized officer
of employer and notarized.
______________________________
EMPLOYEE SIGNATURE
SUBSCRIBED AND SWORN TO BEFORE ME BY _______________________________ ON THIS
______________ DAY OF ______________________ IN THE YEAR: ____________.
______________________________
______________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES
(SEAL)
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Officer as defined herein, means the sole proprietor of a proprietorship; the president, vice president, secretary or
treasurer of a corporation; or, the managing partner of any partnership.
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