Form 211-22 - Application For Refund - 2009
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1OFFICE USE ONLY
2009
VCH#
_____________________
% IN
_____________________
Form 211-22
ACCT#
_____________________
APPLICATION FOR REFUND
______________
____________
INITIALS
DATE
______________
____________
INITIALS
DATE
NOTE: The due date for employer payroll information has been extended to February 28, 2010. Therefore, to allow
adequate verification of payroll amounts, refund processing will begin after March 15, 2010.
Please allow 6-8 weeks for processing
APPLICANT’S SOCIAL SECURITY NO. ____________________________
EMPLOYED BY_______________________________________________
NAME________________________________________________________
ADDRESS _________________________________________________
ADDRESS____________________________________________________
__________________________________________________
_____________________________________________________
DAYTIME TELEPHONE NO. (__________)__________________________
EMAIL ADDRESS ____________________________________________
___________________________________________________________________________________________________________________________
FOR OFFICE USE
(INSTRUCTIONS ON BACK)
ONLY
1.
TOTAL 2009 GROSS COMPENSATION, BEFORE ANY PRETAX DEDUCTIONS
Attach W-2 (s) and any year end earnings summary statements reporting all
wages and local license fee withholding
...................................................................
2.
JOB RELATED EXPENSES......(See instructions)..........................................................
3.
BALANCE (Deduct Line 2 from Line 1)............................................................................
4.
(Complete Form 211-T)
WAGES EARNED OUTSIDE OF FAYETTE COUNTY...
....
For all refunds other than age 65 or over you must complete all parts of Form 211-T…
5.
ADJUSTED GROSS COMPENSATION (Deduct Line 4 from Line 3).............................
6.
-
IF YOU ARE 65 OR OVER DEDUCT $3,000.(DATE OF BIRTH
)...
MONTH - DAY - YEAR
7.
COMPENSATION SUBJECT TO LICENSE FEE (Deduct Line 6 from Line 5)...............
8.
LICENSE FEE WITHHELD FOR THE URBAN COUNTY GOVERNMENT...................
9.
LICENSE FEE DUE (Multiply Line 7 by 2.25%)................................................................
10.
AMOUNT TO BE REFUNDED (Deduct Line 9 from Line 8)..........................................
* PROCESSING WILL BEGIN AFTER MARCH 15, 2010 *
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
___________________________________________________________
____________________________________________________________
AUTHORIZED EMPLOYER SIGNATURE CERTIFYING INFORMATION IS CORRECT
PRINTED NAME
______________________________________________ _________________________
_________________________________________________
TITLE
PHONE NUMBER
DATE
______________________________________________________________________________________________________________________________
Form 211-22 (Rev. 11-2008)
I:/TAXDATA/TAXFORMS/2008/211-T.DOC
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