Request For Refund - City Of Nicholasville, Kentucky
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3CITY OF NICHOLASVILLE
P.O. BOX 590
NICHOLASVILLE, KY 40340-0590
(859) 885-1121
REQUEST FOR REFUND
1. EMPLOYEE NAME
2. SS#
3. CURRENT ADDRESS
4. OFFICE PHONE (
)
5. HOME PHONE
(
)
6. EMPLOYER’S NAME
7. ADDRESS
8. OWNER/MANAGER
9. OFFICE PHONE (
)
10. PAYROLL SUPERVISOR
11. OFFICE PHONE (
)
PART II: EXPLANATION
12. State here (in narrative form)all the facts and circumstances surrounding the request for a refund of City of Nicholasville
Occupational License Fees inappropriately withheld from your wages or paid by you:
(ATTACH DOCUMENTATION)
13. Has the situation been corrected with Payroll Department?
YES
NO
14. Please read the information on the back of this application which explains the City’ refund policy as set forth by City
ordinance.
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