CITY OF NICHOLASVILLE 
                         P.O. BOX 590 
                         NICHOLASVILLE, KY 40340-0590 
                         (859) 885-7618 
                          
                         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 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's refund policy as set 
forth by City Ordinance. 

Request for Refund Form                 Page 1 of 4                                            Revised 6/30/2016 

PART III: REFUND REQUEST 
 
15. Period from ____________________________________ to ______________________________________ 
 
16. Gross wages, commissions and other employee earnings                  16. _____________________________ 
 
17. Total number of days employed during the year               17. ______________________ 
 
18. Number of days from line 17 employed outside City        18. ______________________ 
 
19. Number of days from line 17 employed inside City          19. ______________________ 
 
20. Days employed inside City as a percentage                       20. ______________________ 
       (Line 19 divided by line 17) 
21. Earnings subject to license fee (line 20 x line 16)                                21. ____________________________ 
 
22. License fee due - 1.5% of line 21                                                          22. ____________________________  
 
23. Total City occupational license fee withheld                                        23. ____________________________ 
 
24. Enter refund due - (subtract line 22 from line 23)                                 24. ____________________________ 
 
25. If your claim for overpayment is due to license fees 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 
 
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: ____________________ 

Request for Refund Form                             Page 2 of 4                                            Revised 6/30/2016 

SCHEDULE A 
 
Document below work that was performed outside of the City of Nicholasville.  The total days should agree 
with line 18.  
 
Name of employee claiming refund. _________________________________________ 
 
Date(s)                   Location                                              # of Days 
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________ 
                                                                                Total Days ________ 
                           VERIFICATION 
 
 I, _________________________________state that I am ___________________________________ of 
               (Name)                                    (Title) 
 
______________________________________ , that ___________________________________is an employee  
 (Employer's Name)                                   (Employee claiming refund) 
 
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 before me by ____________________________ this _______________________day of 
                                                                    (Day of Month) 
______________________________, ___________. 
 (Month                         (Year) 
                                                     __________________________________________ 
                                                      Notary Public 
 
                                                     My Commission Expires: ____________________ 

Request for Refund Form                  Page 3 of 4                                            Revised 6/30/2016 

City of Nicholasville Ordinance Sec. 27-8 Subsection (b) 
 
An employee who has compensation attributable to activities performed outside the city, based on time spent 
outside the city, whose employer has withheld and remitted to this city, the occupational license tax on the 
compensation attributable to activities performed outside the city, may file for a refund within two (2) years of 
the date prescribed by law for the filing of a return.  The employee shall provide a schedule and computation 
sufficient to verify the refund claim and the city may confirm with the employer the percentage of time spent 
outside the city and the amount of compensation attributable to activities performed outside the city prior to 
approval of the refund. 

Request for Refund Form                Page 4 of 4                                            Revised 6/30/2016