FORM 211-T
CALCULATION OF WAGES EARNED OUTSIDE OF FAYETTE COUNTY
IMPORTANT - Failure to complete any or all parts of Form 211-T will delay the processing of your refund and may
result in your refund application being returned to you.
PART I - General Information
State your name, social security number, job title, the period you were employed during the refund year and a brief explanation of all the
facts and circumstances surrounding your request for a refund of the license fee.
Name______________________________________________ Social Security # _____________________________
Job Title____________________________________________ Period From _____/_____/ 16 To ____/____/16
Total number of days or hours in period __________________
(i.e. 1/1/16 to 12/31/16 = 366)
Explanation of work performed outside of Fayette County
PART II - Wages Earned Outside of Fayette County
Enter the “Total number of days or hours in period” from PART I.................................................
Subtract days or hours not worked:
a) Saturdays and Sundays (not worked)……………………..
b) Holidays (not worked)………………………………………
c) Sick days or hours (not worked)…………….……………….
d) Vacation days or hours (not worked) …….……….………….
Total days or hours not worked (Add Lines 2a thru 2d)……………….……………………………
Total days or hours worked on this job. (Subtract Line 2 “Total” from Line 1)..............................
Complete Part III, Columns (a) thru (c). Enter total days or hours worked outside of Fayette County,
from PART III, Column (c), Grand Total...........................................................
Divide Line 4 by Line 3. (Carry result to four decimal places.) Enter the result here..............
Enter the amount from Line 1 of Form 211-22, Application for Refund..................................
Multiply Line 6 by Line 5. Enter the result here and on Line 4 of Form 211-22, Application for
Refund
Form 211-T, Revised 12-2016
FORM 211-T
