2019
Form 211-22
APPLICATION FOR REFUND
****REFUND PROCESSING WILL BEGIN AFTER
MARCH 15, 2020****
Please allow 6-8 weeks for processing
EMPLOYED BY_______________________________________________
ADDRESS _________________________________________________
APPLICANT’S SOC. SEC. LAST 4 & DATE OF BIRTH ________________
NAME________________________________________________________
ADDRESS____________________________________________________
__________________________________________________
_____________________________________________________
DAYTIME TELEPHONE NO. (__________)__________________________ EMAIL ADDRESS ____________________________________________
___________________________________________________________________________________________________________________________
TOTAL 2019 GROSS COMPENSATION, BEFORE ANY PRETAX DEDUCTIONS
Attach W-2 (s) and any year end earnings summary statements reporting all
wages and local license fee withholding...................................................................
WAGES EARNED OUTSIDE OF FAYETTE COUNTY...
(Complete Form 211-T)....
For all refunds other than age 65 or over you must complete all parts of Form 211-T…
ADJUSTED GROSS COMPENSATION (Deduct Line 2 from Line 1).............................
IF YOU ARE 65 OR OVER DEDUCT $3,000.(DATE OF BIRTH
-
_____ - _____- ____
)...
COMPENSATION SUBJECT TO LICENSE FEE (Deduct Line 4 from Line 3)...............
LICENSE FEE WITHHELD FOR THE URBAN COUNTY GOVERNMENT...................
LICENSE FEE DUE (Multiply Line 5 by 2.25%)................................................................
AMOUNT TO BE REFUNDED (Deduct Line 7 from Line 6)..........................................
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
___________________________________________________________ ____________________________________________________________
AUTHORIZED EMPLOYER SIGNATURE CERTIFYING INFORMATION IS CORRECT PRINTED NAME
______________________________________________ _________________________ _________________________________________________
TITLE
PHONE NUMBER DATE
______________________________________________________________________________________________________________________________
Form 211-22 (Rev. 1-2020)
OFFICE USE ONLY
VCH# _____________________
% IN _____________________
ACCT# _____________________
______________ ____________
INITIA
LS DATE
______________ ____________
INITIALS DATE
(Valid until Feb. 28, 2022)