Request For Refund - City Of Nicholasville, Kentucky Page 2
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3PART III: REFUND REQUEST
15. Period from ____________________________________ to ______________________________________________
16. Gross Wages, commissions and other employee earnings…………………….16.____________________________________
(Attach copy of W-2 form)
17. Total number of days employed during the year……………………… 17._________________________
18. Number of days from line 17 employed inside City…………………... 18._________________________
19. Days employed inside City as a percentage……………………………
19._________________________
(Line 18 divided by line 17)
20.Earnings subject to license fee (line 19 x line 16)……………………………………. 20._____________________________
21. License fee due – 1 ½ % of line 20…………………………………………………... 21._____________________________
22. Total City occupational license fee withheld………………………………………… 22._____________________________
23. Enter refund due – (subtract line 21 from line 22)…………………………………… 23._____________________________
24. If your claim for overpayment is due to license fee withheld on wages earned by you for work performed outside the City of
Nicholasville, please complete Schedule A and have your employer verify the information supplied thereon.
PART IV: CERTIFICATION
25. I,___________________________________________, do hereby certify that the information contained in the application for
refund of overpayment of Occupational license fee, and all schedules and documentation submitted herewith, is true.
____________________________________________________
Employee Signature
State of Kentucky
County of ________________________________________
Subscribed and sworn before me by __________________________________________ this_______________________ day of
(Day of month)
____________________________,___________.
(Month)
(Year)
_______________________________________
Notary Public
My Commission Expires:_________________
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