Form 0806 - Application For Employee Refund Of Occupational Taxes Withheld

Form 0806 - Application For Employee Refund Of Occupational Taxes Withheld - 2012

Boone County Fiscal Court

PO Box 960

Burlington, KY 41005

859-334-2144 Phone

859-334-3914 Fax

2012 APPLICATION FOR EMPLOYEE REFUND OF OCCUPATIONAL TAXES WITHHELD

Part I: REFUND REASON

_____Boone County taxes withheld on compensation earned outside Boone County

_____Taxes withheld on compensation over the maximum limit

_____Taxes withheld at the incorrect rate

_____School Board tax withheld from wages of employee who was a non-resident of the Boone County School District during all or part of tax year

_____Other: (Must provide detailed explanation)

Part II: EMPLOYER INFORMATION

Employer's Name:

Employer's Federal ID Number:

Employer's Boone County Account Number:

**W2 FORMS MUST BE SUBMITTED WITH APPLICATION OR A DELAY WILL OCCUR**

Part III: APPLICANT INFORMATION

Refund Requested for Year:

Refund Amount (from Pg 2, #16):

Employee's SSN:

Employee's Name:

Employee s Name:

Daytime Phone Number:

Street Address (include Street, City, State & Zip):

Employee's job description:

Part IV: REFUND CALCULATION: This section must be completed by employees requesting a refund. If all work was performed in Boone County, Kentucky, skip to

part IV, Line 6, on page 2 and enter your Gross Compensation and continue with refund calculation. See page 2.

Part V: NON-RESIDENCY STATEMENT: Must be completed if claiming refund as a non-resident of the Boone County School District for the Boone County School

Board tax.

I hereby certify that my residence is: Street Address, City/County/State/Zip

Since: (date or date range)

Part VI: EMPLOYEE'S CERTIFICATION

I hereby certify that the information provided in this refund request is true and correct.

Employee's Signature :

Date:

Part VII: EMPLOYER'S CERTIFICATION (Must be notarized)

I hereby certify that the information provided in this refund request is true and accurate.

Employer's Authorized Signature:

Title:

Date: