Form 211-22 - Application For Refund - 2000
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1OFFICE USE ONLY
2000
LQQ#
_______________________
% IN
_______________________
Form 211-22
ACCT#
______________________
APPLICATION FOR REFUND
Mail return to:
Lexington-Fayette Urban
County Government
Division of Revenue
P.O. Box 14058
Lexington KY 40512
APPLICANT’S SOCIAL SECURITY NO. ____________________________
NAME ___________________________________________________
EMPLOYED BY ___________________________________________________
ADDRESS____________________________________________________ ADDRESS
___________________________________________________
____________________________________________________
___________________________________________________
DAYTIME TELEPHONE NO. (__________)__________________________
___________________________________________________
______________________________________________________________________________________________________________________________
FOR OFFICE USE
(INSTRUCTIONS ON BACK)
ONLY
1.
TOTAL GROSS COMPENSATION IN 2000…..Attach W-2 (s)- (See instructions)……...
2.
JOB RELATED EXPENSES......(See instructions)..........................................................
3.
BALANCE (Deduct Line 2 from Line 1).............................................................................
4.
WAGES EARNED OUTSIDE OF FAYETTE COUNTY...(Use 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 RATE......................................................................................................
2.25%
10.
LICENSE FEE DUE (Multiply Line 7 by Line 9)................................................................
11.
AMOUNT TO BE REFUNDED (Deduct Line 10 from Line 8)..........................................
* PROCESSING WILL BEGIN AFTER FEBRUARY 15, 2001 *
______________________________________________________________________________________________________________________________
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
______________________________________________________________________________________________________________________________
Wages and License Fee verified in DIVISION OF REVENUE by -________________________________________________________
_______________
DATE
Form 211-22 (Rev. 10-2000)
I:/TAXDATA/REVFORMS/REF2000.DOC
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