2021 Form 211-65
(Valid Until February 28, 2024)
APPLICATION FOR REFUND
FOR PERSONS 65 YEARS OR OVER
APPLICANT’S SOCIAL SECURITY NO.________-_______-_____________ AND DATE OF BIRTH ___________/__________/___________
NAME ____________________________________________________ EMPLOYER ____________________________________________________
ADDRESS_________________________________________________ ADDRESS______________________________________________________
__________________________________________________ ______________________________________________________
DAYTIME TELEPHONE NO. (__________)_______________________ EMAIL: ______________________________________________________
________________________________________________________________________________________________________________
TOTAL 2021 GROSS COMPENSATION, BEFORE ANY PRETAX
DEDUCTIONS
Attach all W-2 (s), reporting all wages and local license fee withholding..........
LICENSE FEE WITHHELD FOR THE URBAN COUNTY GOVERNMENT.......
ENTER $68 OR AMOUNT OF WITHHOLDING- WHICHEVER IS LESS…
* PROCESSING WILL BEGIN ON MAY 15, 2022 *
Please allow 10-12 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
______________________________________________________________________________________________________________________________
2021 REFUND INSTRUCTIONS
Line 1: Enter the “Total Gross Compensation”, the amount before any deductions, for 2021. 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
SUPPLIER # ______________
VCH# 00____________________
ACCT# ______________________
______________ ____________
INITIALS DATE
Mail return to: Lexington-Fayette Urban
County Government
Division of Revenue
P.O. Box 14058
Lexington KY 40512
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