Form Rf100 - Application For Refund - 2015 (Page 3 of 4) in pdf

FORM RF100-T

CALCULATION OF WAGES EARNED OUTSIDE OF THE JURISDICTION

IMPORTANT - Failure to complete any or all parts of Form RF100-T will delay the processing of your refund and may result in

your refund application being returned to you.

Please note that this allocation is based upon actual working time. Therefore, you CANNOT calculate “Wages Earned Outside of

the Jurisdiction” using commissions, mileage, etc.

PART I - General Information

State your name, social security number, job title, the period you were employed during the refund year and a brief explanation of all the

facts and circumstances surrounding your request for a refund of the license fee.

Name______________________________________________

Social Security # _____________________________

Job Title____________________________________________

Period From _____/_____/ 15 To ____/____/ 15

Total number of days/hours in period __________________

(i.e. 1/1/15 to 12/31/15 = 365)

Explanation

PART II - Wages Earned Outside of the Jurisdiction

Enter the “Total number of days/hours in period” from PART I.................................................

Subtract days/hours not worked:

a) Saturdays and Sundays (not worked)……………………..

b) Holidays (not worked)………………………………………

c) Sick days/hours (not worked)…………….……………….

d) Vacation days/hours (not worked) …….……….………….

Total days/hours not worked (Add Lines 2a thru 2d)……………….……………………………

Total days/hours worked on this job. (Subtract Line 2 “Total” from Line 1)..............................

Complete Part III, Columns (a) thru (c). Enter total days/hours worked outside of the Jurisdiction,

from PART III, Column (c), Grand Total...........................................................

Divide Line 4 by Line 3. (Carry result to four decimal places.) Enter the result here..............

Enter the amount from Line 1 of Form RF100, Application for Refund..................................

Multiply Line 6 by Line 5. Enter the result here and on Line 2 of Form RF100, Application for

Refund

Form RF100-T, Revised 10-2015

Form Rf100 - Application For Refund - 2015 Page 3