Refund Request Form Kentucky - Occupational Tax Office

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Phone: 270/ 842-7168
REV 5/04
Fax: 270/ 842-3411
WARREN COUNTY SCHOOLS
OCCUPATIONAL TAX OFFICE
P. O. BOX 51530
BOWLING GREEN, KY 42102-5830
REFUND REQUEST FORM
EMPLOYER NAME
FEDERAL ID #
EMPLOYEE NAME
SOCIAL SEC. #
MAILING ADDRESS
HOME PHONE#
CITY, STATE, ZIP
WORK PHONE#
PERIOD IN WHICH APPLYING FOR REFUND
FROM
TO
REASON APPLYING FOR REFUND
IF APPLYING FOR MULTIPLE YEARS COMPLETE SECTION I
W2(S) AND PROOF OF RESIDENCY ARE REQUIRED FOR ALL REFUNDS
SECTION I
TAX YEAR
GROSS WAGES $
REFUND AMOUNT $
TAX YEAR
GROSS WAGES $
REFUND AMOUNT $
TAX YEAR
GROSS WAGES $
REFUND AMOUNT $
$
TOTAL REFUND
IF APPLYING FOR A PARTIAL REFUND COMPLETE SECTION II
SECTION II
W2 AND EVIDENCE OF NON TAXABLE INCOME ARE REQUIRED
1.
Gross Wages…………………………………………………………………………………..
2.
Warren County Occupational Tax Withheld………………………………………………….
3.
Total Number of Days Worked During the Year……………………………………………..
4.
Number of Days Worked Outside Bowling Green, Warren County………………………….
5.
Percentage Outside Bowling Green, Warren County (line 4 divided by line 3)………………
6.
Wages Not Subject to Warren County Occupational Tax (line 1 x line 5)……………………
7.
Refund Due (line 6 x line .005)………………………………………………………………..
EMPLOYEE SIGNATURE
DATE

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