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CAMPBELL COUNTY & CITIES, KENTUCKY

CCOT Refund Form 0314

EMPLOYEE REFUND OF OCCUPATIONAL TAXES WITHHELD

(Instructions on Reverse--Read Carefully)

OFFICE USE ONLY

MAIL COMPLETED FORM TO:

App date

_______

Campbell County Fiscal Court Occupational License Dept.  P.O. Box 72958  Newport, KY 41072-0958

Initial

_______

Ref Amt $ _______

Please complete the following and return to the address above. All applicable sections must be completed

Ref YR

_______

in order to process refund request. Refunds must be requested within two (2) years of the date the

Loc Code _______

overpayment was made.

Acct ID

_______

Part I: Employee Information

Name of Refund Applicant ________________________________________ 4. Refund Year _______________________

Mailing Address ________________________________________________

5. Refund Amount $___________________(from Line 22)

City, State, Zip _________________________________________________ 6. Residence City _____________________

Part II: Employer Information

Name of Employer ___________________________________________________________________________________

City of Employment _____________________________________________ 10. Employer or Business

Employer’s Federal ID or Soc. Sec. No.: _____________________________

Occupational License # _______________

Part III: Refund Explanation

11. Check the locality for which a refund is claimed. FILE SEPARATE FORM FOR EACH REFUND LOCALITY.

_____ Campbell County

_____ Alexandria City

____ Cold Spring City

____ Ft Thomas City

_____ Highland Heights City _____ Melbourne City

____ Southgate City

____ Woodlawn City

12. Explanation for Refund:

_____ Paid in excess of maximum tax (MUST attach copy of W-2(s))

_____ Overpaid due to excluded earnings (Complete Lines 13 to 22 below)

_____ Other (Explain) _______________________________

Part IV: Refund Calculation

Lines 13 to 22 must be completed by employees requesting refunds for work performed outside the locality checked on Line 11.

13. List ALL localities below along with the number of hours worked outside the city or locality ABOVE during the refund year.

(If more than 3 localities, attach additional sheet with requested information.)

City _________________________ County ________________________ State ______ Number of Hours Worked ______

Check applicable Quarters ______ 1

Jan-Mar _____ 2

Apr-Jun _____ 3

Jul-Sep _____ 4

Oct-Dec

14. _________ Number of hours worked outside of Locality checked on Line 11.

15. _________ Total number of hours worked, excluding Holiday, vacation and sick days. Normal work year = 2080 hours.

16. _________ Percentage of time worked outside Locality checked on Line 11 -- divide Line 14 by Line 15.

17. _________ Total gross wages including deferred compensation per W-2 Form (Box 5 or Box 18, whichever is greater)

18. _________ Total wages earned outside Locality on Line 11 -- multiply Line 16 X Line 17.

19. _________ Local taxable wages -- Subtract Line 17 – Line 18.

20. _________ Occupational tax due – multiply Line 19 X applicable rate -- see Rate Table.

21. _________ Amount of tax withheld per W-2 Form or year to date payroll stub -- submit copy with this form.

22. _________ Amount of refund requested – if Line 21 is greater than Line 20, subtract Line 21 – Line 20

I hereby certify that the statements made herein and on supporting schedules are true

and correct to the best of my knowledge. (Not required for taxes withheld on

I hereby certify that the statements made herein and on supporting schedules are true and

compensation over the maximum limit from 2 or more employers)

correct to the best of my knowledge.

EMPLOYEE SIGNATURE

Date

EMPLOYER’S AUTHORIZED SIGNATURE

Date

Printed name of employee

Printed Name

Title

Home Telephone

Work Telephone

Telephone



All refund checks will be mailed to the street address provided in Lines 2 and 3 above.



A 1099 G form will be issued to all employees at the end of the tax year on any refund over $10.00 dollars.



A copy of Form W-2 or year to date payroll check stub must be submitted with this application.



Statements for out of county/city work should be taken from daily logs or calendars/schedules that this agency reserves the right to audit .

Ccot Refund Form 0314 Employee Refund Of Occupational Taxes Withheld - Campbell County & Cities, Kentucky - 2014

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