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                                                                                               OFFICE USE ONLY 
                                                                                               VCH#  _______________________ 
                                    201 8Form 211-65 
                                                  (Valid until Feb. 28, 2021)                  ACCT#   ______________________ 
                                                                                               ______________         ____________ 
                               APPLICATION FOR REFUND                                            INITIALS                 DATE 
                            FOR PERSONS 65 YEARS OR OVER 

APPLICANT’S LAST 4 DIGITS OF SOCIAL SECURITY NO. AND DATE OF BIRTH __________________________ 

NAME ____________________________________________________     EMPLOYED BY____________________________________________________ 

ADDRESS__________________________________________________     ADDRESS________________________________________________________ 

        __________________________________________________                  _______________________________________________________ 

DAYTIME TELEPHONE NO.  (__________)_______________________ 

DATE OF BIRTH ___________________________________________ 
                               MONTH/DAY/YEAR 
______________________________________________________________________________________________________________________________ 
                                                                                                                    FOR OFFICE USE 
                                                                                                                     ONLY 

1TOTAL 201 8GROSS COMPENSATION, BEFORE ANY PRETAX 
  DEDUCTIONS 
  Attach all W-2 (s), reporting all wages and local license fee withholding.......... 

2 LICENSE FEE WITHHELD FOR THE URBAN COUNTY GOVERNMENT....... 

3 
  ENTER $68 OR AMOUNT OF WITHHOLDING- WHICHEVER IS LESS

                                                                                    * PROCESSING WILL BEGIN AFTER MARCH 15, 2019 *
                                                                                                        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 
______________________________________________________________________________________________________________________________ 

                                              201 8REFUND INSTRUCTIONS 

Line 1: Enter the “Total Gross Compensation”, the amount before any deductions, for 201 . This8includes 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.  
                               Mail return        to: Lexington-Fayette Urban 
                                                      County Government  
                                                      Division of Revenue  
                                                      P.O. Box 14058 
                                                      Lexington KY  40512 






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