Form A - Quarterly Claim - Application For Employee Payment Of Less Than 100% Of Occupational Tax Page 2
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2SECTION 4 – EMPLOYEE SWORN STATEMENT
I hereby swear to and certify that all information provided on this Application for Employee Payment of less
than 100% of Occupational Tax - (FORM A – Quarterly Claim) is complete, and that the percentage of time
worked in the City of Jeffersontown (Line 14) is true and accurate to the best of my knowledge. I have
attached written proof of this claim in form of the following:
a. Mileage logs or schedule of total hours work inside and outside of the City of Jeffersontown,
KY.
b. Written employer statement of explanation regarding Employee time worked inside and outside
the City of Jeffersontown, KY. (Any additional information and/or written explanation relating to
this FORM A – Quarterly Claim must be signed and notarized by an authorized officer of
employer.)
________________________________________
EMPLOYEE SIGNATURE
Subscribed and sworn to before me by ______________________________________________
on this ___________ day of _______________________________ in the year of ___________________.
________________________________________
NOTARY PUBLIC
________________________________________
COMMISSION EXPIRES
SECTION 5 – EMPLOYER SWORN STATEMENT
_________________________________________________
Authorized Officer** for ______________________________
I hereby certify that _______________________________________________________,
employee of ______________________________________, worked _________ % of his/her total hours
worked in ________________ of ____________ inside the City of Jeffersontown, KY. This certification is
2013
based upon the following:
a. Mileage logs or schedule of total hours work inside and outside of the City of Jeffersontown,
KY.
b. Written employer statement of explanation regarding Employee time worked inside and outside
the City of Jeffersontown, KY. (Any additional information and/or written explanation relating to
this Application for Employee Payment of less than 100% of Occupational Tax - (FORM A –
Quarterly Claim) must be signed and notarized by an authorized officer of employer.)
_____________________________________________
AUTHORIZED OFFICER ** SIGNATURE
Subscribed and sworn to before me by ______________________________________________
on this ___________ day of _______________________________ in the year of ___________________.
________________________________________
NOTARY PUBLIC
________________________________________
COMMISSION EXPIRES
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