Form B-Annual Claim - Application For Employee Refund Of Occupational Tax - City Of Jeffersontown, Ky Page 2
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2SECTION 4 – EMPLOYEE / APPLICANT SWORN STATEMENT
I hereby swear to and certify that all information provided on this Application for Refund for
Occupational Tax (Form B – Annual Claim) is complete, and that the percentage of time worked in the City
of Jeffersontown (Line 15) is true and accurate to the best of my knowledge. I have attached written proof
of this claim in form of the following:
a. Mileage logs or schedule of total hours work inside and outside of the City of Jeffersontown,
KY.
b. Written employer statement of explanation regarding Employee time worked inside and outside
the City of Jeffersontown, KY. (Any additional information and/or written explanation relating to
employee refund request of occupational tax must be signed and notarized by an authorized
officer of employer.
________________________________________
EMPLOYEE / APPLICANT SIGNATURE
Subscribed and sworn to before me by ______________________________________________
on this ___________ day of _______________________________ in the year of ___________________.
________________________________________
NOTARY PUBLIC
________________________________________
COMMISSION EXPIRES
SECTION 5 – EMPLOYER SWORN STATEMENT AND EXPLANATION FOR REFUND
_________________________________________________
Authorized Officer** for ______________________________
I hereby certify that _______________________________________________________,
employee of ______________________________________, worked _________ % of his/her total hours
worked in the year of ___________ inside the City of Jeffersontown, KY. This certification is based upon
2013
the following:
a. Mileage logs or schedule of total hours work inside and outside of the City of Jeffersontown,
KY.
b. Written employer statement of explanation regarding Employee time worked inside and outside
the City of Jeffersontown, KY. (Any additional information and/or written explanation relating to
employee refund request of occupational tax must be signed and notarized by an authorized
officer of employer.
_____________________________________________
AUTHORIZED OFFICER ** SIGNATURE
Subscribed and sworn to before me by ______________________________________________
on this ___________ day of _______________________________ in the year of ___________________.
________________________________________
NOTARY PUBLIC
________________________________________
COMMISSION EXPIRES
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