Form A - Quarterly - Application For Employee Payment Of Less Than 100% Of Occupational Taxes
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3CITY OF JEFFERSONTOWN, KY
FORM “A” (Quarterly)
Application for Employee payment of less than 100% of Occupational Taxes
Phone: (502) 267-8333
Fax: (502) 267-0547
SECTION 1 - EMPLOYEE – EMPLOYER INFORMATION
APPLICATION DATE:
_________________
REQUEST FOR QUARTER OF: _________________
EMPLOYEE NAME:
_______________________________________________________________________
MAILING ADDRESS:
_______________________________________________________________________
POSITION:
_______________________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------
EMPLOYER NAME:
_______________________________________________________________________
STREET ADDRESS:
_______________________________________________________________________
EMPLOYER FED. ID. #
____________________________
PHONE: __________________________
DESCRIPTION OF BUSINESS: _________________________________________________________________________________
SECTION II – WORKSHEET
Line 1
________________________
Total Gross Wages (including deferred compensation)
Line 2
________________________
Total number of Hours worked for applicable period
Line 3a
________________________
Total number of Hours worked INSIDE City of Jeffersontown
Line 3b
________________________
Total number of “Time Off” hours
(Add all Vacation, Sick, Holiday, LOA & other Time Off hours)
Line 3
________________________
Adjusted number of hours worked INSIDE City of Jeffersontown
(Add Line 3a to Line 3b for adjusted hours)
Line 4
________________________
% of time worked INSIDE Jeffersontown (divide Line 3 by Line 2)
Line 5
________________________
Local Taxable Wages (Line 1 x Line 4)
Line 6
________________________
Occupational tax due (Line 5 x tax rate of 1.0%)
Line 7
________________________
Amount of tax withheld
Line 8
________________________
Difference (subtract Line 6 from Line 7)
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