Form Rf100-65 - Application For Refund - 2010
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1
22010
Mail return to:
Georgetown-Scott County
Form RF100-65
Revenue Commission
P.O. Box 800
APPLICATION FOR REFUND
Georgetown, KY 40324
APPLICANT’S SOCIAL SECURITY NO. __________________________
APPLICANT’S DATE OF BIRTH ____________________________
NAME ___________________________________________________
EMPLOYED BY ___________________________________________________
ADDRESS____________________________________________________ ADDRESS
___________________________________________________
____________________________________________________
___________________________________________________
DAYTIME TELEPHONE NO. (__________)__________________________
___________________________________________________
______________________________________________________________________________________________________________________________
City of Georgetown
Scott County
(INSTRUCTIONS ON BACK)
1.
TOTAL 2010 GROSS COMPENSATION, BEFORE ANY PRETAX
Attach W-2 (s) and any year end earnings
DEDUCTIONS --
summary statements reporting all wages and local license fee
withholding
................................................................................
2.
EXEMPTION AMOUNT
$10,000
$10,000
3.
ADJUSTED GROSS COMPENSATION…(Line 2 less Line 1).........
4.
LICENSE TAX WITHHELD FOR THE JURISDICTION......................
1%
1%
5.
LICENSE TAX RATE........................................................................
6.
LICENSE TAX DUE (Multiply Line 3 by Line 5).................................
7.
AMOUNT TO BE REFUNDED (Deduct Line 6 from Line 4)...............
Please allow 6-8 weeks for processing.
______________________________________________________________________________________________________________________________
I HEREBY CERTIFY THAT THE STATEMENTS MADE HEREIN AND IN ANY SUPPORTING SCHEDULES ARE TRUE, CORRECT AND COMPLETE TO
THE BEST OF MY KNOWLEDGE.
RETURN MUST
______________________________________________ BE SIGNED _______________________________________________
__________________
SIGNATURE OF INDIVIDUAL PREPARING RETURN
SIGNATURE OF APPLICANT
DATE
______________________________________________________________________________________________________________________________
Wages and License Tax verified by -________________________________________________________
_______________
DATE
Form RF100 (Rev. 10-2010)
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