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Form A - Quarterly - Application For Employee Payment Of Less Than 100% Of Occupational Taxes Page 3

SECTION IV – EXPLANATION & EMPLOYER STATEMENT

________________________________________________________

(NAME & TITLE - AUTHORIZED OFFICER OF EMPLOYER)

______________________________________________

(EMPLOYER NAME)

______________________________________________

(EMPLOYEE NAME)

I hereby certify that the above listed employee worked ____________% of his/her total hours worked in the quarter of

_____________________ inside the City of Jeffersontown. This certification is based upon 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.

___________________________________________________

AUTHORIZED OFFICER OF EMPLOYER SIGNATURE

SUBSCRIBED AND SWORN TO BEFORE ME BY _______________________________ ON THIS

______________ DAY OF ______________________ IN THE YEAR: ____________.

______________________________

NOTARY PUBLIC

MY COMMISSION EXPIRES

(SEAL)

SECTION V – GENERAL INFORMATION

STATEMENTS FOR WORK OUTSIDE THE CITY OF JEFFERSONTOWN: Statements for work outside the

City of Jeffersontown should be taken from mileage logs, daily logs or calendar schedules. The City of Jeffersontown

reserves the right to audit applications in the case of discrepancies. Employee and Employer will be notified in writing

when an audit is required. Such notification shall be mailed to addresses provided on the application.

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 3