Form 211-22 - Application For Refund - 2015
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1OFFICE USE ONLY
2013
VCH#
_____________________
% IN
_____________________
Form 211-22
ACCT#
_____________________
APPLICATION FOR REFUND
______________
____________
INITIALS
DATE
______________
____________
INITIALS
DATE
****REFUND PROCESSING WILL BEGIN AFTER MARCH 15, 2014****
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 2013 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
)...
_____ - _____- ____
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)..........................................
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. 11-2012)
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