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Form A - Quarterly - Application For Employee Payment Of Less Than 100% Of Occupational Taxes Page 2

SECTION III – EXPLANATION & EMPLOYEE STATEMENT

I hereby certify that the above information on page one (1) is complete and accurate to the best of my ability. I further

state that the percentage of time worked (Line 4) In the City of Jeffersontown is accurate. Upon request, I will provide

written proof of such claim in the form of the following:

•

Mileage logs or schedule of total hours worked inside and outside the City of Jeffersontown

•

Written Employer statement of explanation concerning Employee time worked inside and outside the City of

Jeffersontown. (Any additional information and/or written explanation relating to employee request for

refund of occupational taxes must be signed by authorized officer

of employer and notarized.

______________________________

EMPLOYEE SIGNATURE

SUBSCRIBED AND SWORN TO BEFORE ME BY _______________________________ ON THIS

______________ DAY OF ______________________ IN THE YEAR: ____________.

______________________________

NOTARY PUBLIC

MY COMMISSION EXPIRES

(SEAL)

Officer as defined herein, means the sole proprietor of a proprietorship; the president, vice president, secretary or

treasurer of a corporation; or, the managing partner of any partnership.

Form A - Quarterly - Application For Employee Payment Of Less Than 100% Of Occupational Taxes Page 2