2017 Form 211-65
APPLICATION FOR REFUND
FOR PERSONS 65 YEARS OR OVER
If your refund claim is for wages earned outside Fayette County
or unreimbursed expenses, you must use Form 211-22.
APPLICANT’S SOCIAL SECURITY NO. __________________________
NAME ____________________________________________________ EMPLOYED BY____________________________________________________
ADDRESS__________________________________________________ ADDRESS________________________________________________________
__________________________________________________ _______________________________________________________
DAYTIME TELEPHONE NO. (__________)_______________________ ______________________________________________________
DATE OF BIRTH ___________________________________________
MONTH/DAY/YEAR
______________________________________________________________________________________________________________________________
1
TOTAL 2017 GROSS COMPENSATION, BEFORE ANY PRETAX
DEDUCTIONS
Attach all W-2 (s), reporting all wages and local license fee withholding..........
LI
CENSE FEE WITHHELD FOR THE URBAN COUNTY GOVERNMENT.......
EN
TER
$68 OR AMOUNT OF WITHHOLDING- WHICHEVER IS LESS…
PROCESSING WILL BEGIN AFTER MARCH 15, 2018 *
Please allow 6-8 weeks for processing.
______________________________________________________________________________________________________________________________
I HEREBY CERTIFY THAT THE STATEMENTS MADE HEREIN AND IN ANY SUPPORTING SCHEDULES ARE TRUE, CORRECT AND COMPLETE TO
THE BEST OF MY KNOWLEDGE.
RETURN MUST
______________________________________________ BE SIGNED _______________________________________________ __________________
SIGNATURE OF INDIVIDUAL PREPARING RETURN SIGNATURE OF APPLICANT DATE
______________________________________________________________________________________________________________________________
2017 REFUND INSTRUCTIONS
Line 1: Enter the “Total Gro
ss Compensation”, the amount before any deductions, for 2017. This includes income from salaries, wages,
bonuses, severance and/or termination pay, deferred compensations and/or pension plans, cafeteria plans, etc. and amounts
received for approved leave including, but not limited to, vacation, sick or holiday pay. This is generally found in box 18 of the
W-2 form.
Line 2: Enter the actual amount of license fee withheld from your compensation for the year. DO NOT include amounts that were
withheld for the Fayette County Public Schools.
Line 3: Enter $68 or amount of withholding from Line 2 - whichever is less. This is the amount of your refund.
OFFICE USE ONLY
VCH# _______________________
ACCT# ______________________
______________ ____________
INITIALS DATE
Mail return to: Lexington-Fayette Urban
County Government
Division of Revenue
P.O. Box 14058
Lexington KY 40512
