CITY OF NICHOLASVILLE 
                           P.O. BOX 590 
                         NICHOLASVILLE, KY  40340-0590 
                           (859) 885-1121 
                             
                          REQUEST FOR REFUND 
 
1.   EMPLOYEE NAME           2.   SS# 
 
3.   CURRENT ADDRESS         4.   OFFICE PHONE  (     ) 
 
                             5.   HOME PHONE    (     ) 
 
6.   EMPLOYER’S NAME 
 
7.   ADDRESS 
 
8.   OWNER/MANAGER           9.   OFFICE PHONE  (     ) 
 
10.  PAYROLL  SUPERVISOR     11.  OFFICE PHONE (     ) 
 
PART II:  EXPLANATION 
 
12.  State here (in narrative form)all the facts and circumstances surrounding the request for a refund of City of Nicholasville 
Occupational License Fees inappropriately withheld from your wages or paid by you: 
(ATTACH DOCUMENTATION) 
 
13.  Has the situation been corrected with Payroll Department?                YES            NO 
 
14.  Please read the information on the back of this application which explains the City’ refund policy as set forth by City       
ordinance. 

PART III: REFUND REQUEST 
 
15. Period from ____________________________________ to ______________________________________________ 
 
16. Gross Wages, commissions and other employee earnings…………………….16.____________________________________ 
      (Attach copy of W-2 form) 
17. Total number of days employed during the year………………………    17._________________________ 
 
18. Number of days from line 17 employed inside City…………………...    18._________________________ 
 
19. Days employed inside City as a percentage……………………………     19._________________________ 
      (Line 18 divided by line 17) 
20.Earnings subject to license fee (line 19 x line 16)…………………………………….    20._____________________________ 
 
21. License fee due – 1 ½ % of line 20…………………………………………………...    21._____________________________ 
 
22. Total City occupational license fee withheld…………………………………………    22._____________________________ 
 
23. Enter refund due – (subtract line 21 from line 22)……………………………………    23._____________________________ 
 
24. If your claim for overpayment is due to license fee withheld on wages earned by you for work performed outside the City of  
      Nicholasville, please complete Schedule A and have your employer verify the information supplied thereon. 
 
PART IV: CERTIFICATION 
 
25. I,___________________________________________, do hereby certify that the information contained in the application for  
 
refund of overpayment of Occupational license fee, and all schedules and documentation submitted herewith, is true. 
 
                                                                                       ____________________________________________________ 
                                                                                                  Employee Signature 
 
State of Kentucky  
 
County of ________________________________________ 
 
Subscribed and sworn before me by __________________________________________ this_______________________ day of  
                                                                                                                                                               (Day of month) 
 
____________________________,___________. 
      (Month)                                        (Year) 
 
                                                                                                                                  _______________________________________ 
                                                                                                                                                Notary Public 
 
                                                                                                                                   My Commission Expires:_________________ 
 

SCHEDULE    A 
 
Documentation for refund of license fee withheld on compensation earned for work performed outside of City of Nicholasville. 
 
Name of employee claiming refund. ____________________________________________________ 
 
    Month                               Date(s)            Location                                                                            Days 
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________ 
 
“Total number of days employed during entire period ______________ less number of days claimed as employment outside the 
City _____________, equals number of days employed inside the city.  (Must agree with line 18) 
 
                                                                                    VERIFICATION 
                                                                                     
 I,_________________________________________ state that I am _______________________________________ of 
                              (Name)                                                                                                      (Title) 
 
_________________________________________ Company, that _________________________________________ is an   
           (Employer’s Name)                                                                           (Employee claiming refund) 
 
employee of such company, and that I have reviewed the above information supplied by the employee and that it is true and  
 
correct to the best of my knowledge and belief. 
 
                                                                                                     _________________________________________________ 
                                                                                                             (Signature) 
 
State of Kentucky 
 
County of _________________________________________ 
 
Subscribed and sworn to before me by ____________________________________as_________________________________of 
 
__________________________________company this __________________ day of ______________________, ___________. 
                                                                                               (Day of month)                          (Month)                             (Year) 
 
                                                                                                 ___________________________________________________ 
                                                                                                        Notary Public 
 
                                                                                                  My Commission Expires: _____________________________ 
 

City of Nicholasville Ordinance Sec. 21-56, Subsection C 
 
In the event that an employee, who is paying city payroll taxes to the city of Nicholasville, discovers that there was any error 
made in either the collecting or reporting concerning his or her city employee payroll tax, then that person may apply to the 
Board of Commissioners for adjustment in his payroll tax, which will more properly reflect and be a valid assessment for the time 
in which said employee worked within the city limits of the City of Nicholasville.  In the event that the Board of Commissioners 
determines that there is an inequity resulting from overpayment of tax, the Board of Commissioners may grant refunds to 
properly reflect that appropriate taxing.  Applications for such refunds must be made in writing and must not exceed a period of 
time greater than two years from the date funds might have been paid or withheld.