Form 0806 - Application For Employee Refund Of Occupational Taxes Withheld

Form 0806 - Application For Employee Refund Of Occupational Taxes Withheld - 2012 Page 2

Boone County Fiscal Court

PO Box 960

Burlington, KY 41005

859-334-2144 Phone

859-334-3914 Fax

Name: _________________________________________

SSN:_____________________________________________

Please fill out the below data for the above noted employee for tax year 2012. Total work time spent, both in Boone County

and in other locations should total 100% of hours worked. You may use a separate sheet of paper if necessary.

Name of County/City/State

Number of Hours(Spent working in this jurisdiction)

________________________________________

1. Number of hours worked outside Boone (per schedule above)

_____________________

2. Total number of hours worked*

_____________________

*(excluding holiday, vacation, and sick days - normal work year = 2080 hours)

3. Percentage of time worked outside Boone

_____________________

4. Total Gross wages per W2 Form, including deferred compensation

_____________________

5. Total wages earned outside Boone County

_____________________

6. Total taxable Boone County Wages

_____________________

Board of Education Tax

7. Adjusted Tax liability - 1/2 of 1% (Line 6 *.005)

_____________________

8. Boone County Board of Education Tax withheld from W2

_____________________

9. Boone County Board of Education Tax - (Refund)/Payment

_____________________

Boone County Ordinance Tax

10. Adjusted Tax liability - 8/10 of 1% (Line 6 *.008) not to exceed $444.75

_____________________

11. Boone County Ordinance #07-27 withheld from W2

_____________________

12. Boone County Ordinance #07-27 - (Refund)/Payment

_____________________

Boone County Mental Health Tax

13. Adjusted Tax liability- 15/100 of 1% (Line 6 *.0015)not to exceed $25

_____________________

14. Boone County Mental Health Tax withheld from W2

_____________________

15. Boone County Mental Health Tax - (Refund)/Payment

_____________________

16. Total (Refund)/Payment (transfer to Part III on page 1)

_____________________

Form 0806 Page 2

Form 0806 - Application For Employee Refund Of Occupational Taxes Withheld - 2012 Page 2

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