Form A - Quarterly Claim - Application For Employee Payment Of Less Than 100% Of Occupational Tax

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CITY OF JEFFERSONTOWN, KY
Application for Employee Payment of less than
100% of Occupational Tax - (FORM A – Quarterly Claim)
jeffersontownky.gov
SECTION 1 – EMPLOYEE INFORMATION
May 19, 2014
2013
1. Application Date: _______________________
2. For Tax Period: ______________ of ____________
Tax Quarter
Year
3. Employee Name: ____________________________________________________________________
4. Employee Social Security No.: __________________________________________________________
SECTION 2 – EMPLOYER INFORMATION
5. Employer Name: _____________________________________________________________________
6. Employer Address: __________________________________________________________________
7. City, State, Zip Code: ________________________________________________________________
8. Employer Phone Number: _____________________________________________________________
9. Employer Federal Tax ID: _____________________________________________________________
SECTION 3 – CLAIM WORKSHEET
10. Total Gross Wage: ..………………………………………………………….…..…
__________
(Include deferred compensation)
11. Total number of hours worked in __________________ of ___________: …..
2013
__________
Tax Quarter
Year
12. Total number of hours worked INSIDE Jeffersontown: ……………..……….…...
__________
13. Total number of ‘Time Off’ hours: ………………………………………………...…
__________
(Include all, vacation, sick, holiday, LOA & any other time off)
14. Adjusted number of hours worked INSIDE Jeffersontown: …………..…….……
__________
(Add line 12 to line 13 for adjusted hours)
15. Percent (%) of time worked INSIDE Jeffersontown: ……………………….…..…
__________
(Divide line 14 by line 11)
16. Jeffersontown taxable wages: …………………………………….………….……..
__________
(Multiply line 10 by line 15)
17. Jeffersontown local tax due: …………………………………….……………..……
__________
(Multiply line 16 by 0.01)
18. Amount of tax withheld: ……………………………………..………….………...…
__________
19. Amount of reduction in tax remittance: ……….…….………………………….….
__________
(Subtract line 17 from line 18)
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