Form B - Annual Claim - Application For Employee Refund Of Occupational Taxes Paid Page 3
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3SECTION IV – EXPLANATION FOR REFUND & EMPLOYER STATEMENT
________________________________________________________
(NAME & TITLE - AUTHORIZED OFFICER OF EMPLOYER)
______________________________________________
(EMPLOYER NAME)
______________________________________________
(EMPLOYEE NAME)
I hereby certify that the above listed employee worked ____________% of his/her total hours worked in the year of
2012
__________ inside the City of Jeffersontown. This certification is based upon 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.
___________________________________________________
AUTHORIZED OFFICER OF EMPLOYER SIGNATURE
SUBSCRIBED AND SWORN TO BEFORE ME BY _______________________________ ON THIS
______________ DAY OF ______________________ IN THE YEAR: ____________.
______________________________
______________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES
(SEAL)
SECTION V – GENERAL INFORMATION
STATEMENTS FOR WORK OUTSIDE THE CITY OF JEFFERSONTOWN: Statements for work outside the
City of Jeffersontown should be taken from mileage logs, daily logs or calendar schedules. The City of Jeffersontown
reserves the right to audit applications in the case of discrepancies. Employee and Employer will be notified in writing
when an audit is required. Such notification shall be mailed to addresses provided on the application.
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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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