Request For Refund - City Of Nicholasville, Kentucky Page 3
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3SCHEDULE
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Documentation for refund of license fee withheld on compensation earned for work performed outside of City of Nicholasville.
Name of employee claiming refund. ____________________________________________________
Month
Date(s)
Location
Days
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
“Total number of days employed during entire period ______________ less number of days claimed as employment outside the
City _____________, equals number of days employed inside the city. (Must agree with line 18)
VERIFICATION
I,_________________________________________ state that I am _______________________________________ of
(Name)
(Title)
_________________________________________ Company, that _________________________________________ is an
(Employer’s Name)
(Employee claiming refund)
employee of such company, and that I have reviewed the above information supplied by the employee and that it is true and
correct to the best of my knowledge and belief.
_________________________________________________
(Signature)
State of Kentucky
County of _________________________________________
Subscribed and sworn to before me by ____________________________________as_________________________________of
__________________________________company this __________________ day of ______________________, ___________.
(Day of month)
(Month)
(Year)
___________________________________________________
Notary Public
My Commission Expires: _____________________________
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