CITY OF ST. MATTHEWS 
               APPLICATION FOR EMPLOYEE REFUND OF OCCUPATIONAL TAXES WITHHELD 
                                             3940 GRANDVIEW AVENUE 
                                                LOUISVILLE KY 40207 
                                     OFFICE (502) 895-9444     FAX (502)895-0510 
                                                            
PART I: (Please Print) 

Employer’s Name: _________________________________________________________________________ 

Employer’s Federal ID #: ____________________________________________________________________ 

Employer’s St. Matthews Acct #: _______________________ 

PART II:  

Refund Requested for Year: _______________              Employee’s SSN#: ___________________________ 

Employee’s Name: __________________________________        Phone #: ___________________________ 

Street Address (include city, state & zip code): _________________________________________________ 

Employee’s Job Description: ________________________________________________________________ 

PART III:(This section must be completed to request a refund for work performed outside of St. Matthews.)                  
                                         st                nd                rd             th
Quarters Involved in Overpayment:         1                  2                    3              4  

(select applicable quarters)                  Jan – March          April – June          July – Sept           Oct – Dec  
 
Line 1 __________ Number of Hours Worked Outside St. Matthews 
Line 2 __________ Total Number of Hours Worked (excluding holiday, vacation, and sick days) [normal work year = 2,080 hours] 
Line 3 __________ Percentage of Time Worked Outside St. Matthews (divide line 1 by line 2)  
                  (Note: Must be more than 5% (104 hours) to claim refund.)  
Line 4 __________ Total Gross Wages (including deferred compensation) per W2 Form 
Line 5 __________ Total Wages Earned Outside St. Matthews (multiply line 3 by line 4) 
Line 6 __________ Local Taxable Wages (line 4 – line 5) 
Line 7 __________ Occupational Tax Due (multiply line 6 by applicable tax rate .0075) 
Line 8 __________ Amount of Tax Withheld per W2 Form or Year to Date Payroll Check Stub   ( copy required) 
Line 9 __________ Amount of Refund Requested (subtract line 7 from Line 8) 
 
PART IV:  (Explanation for Refund) 
 
                                         st                nd                rd             th
Quarters Involved in Overpayment:        1                  2                    3              4  
(select applicable quarters)                 Jan – March         April – June         July – Sept          Oct – Dec  
 
1. __________ Occupational Taxes Withheld at a Higher Rate Than .0075  

2. __________ Other (must provide detailed explanation) _____________________________________________ 

If you are requesting a refund as a result of one of the items described on Lines 1-2, please enter the amount of refund 

you are requesting: $ _____________________ 

PART V:  (CERTIFICATION)  

I hereby certify that the above information is true and correct.  

Employee Signature: ____________________________________________________ Date: ________________ 

Corporate Office Signature: ______________________________________________ Date: ________________ 

   Subscribed and sworn to before me this __________ day of _________________________, 20_______,  

by __________________________________________.  

My Commission Expires: ________________________ 

                                                 Notary Public, State at Large, ______________________ 

  All refund checks will be mailed to the street address provided in Part II. 
  A copy of form W2 or year to date payroll check stub must be submitted with this application.  
    
   Statements for out of town work should be taken from daily logs or calendar/schedules that this agency reserves 
   the right to audit in case of discrepancies.  
 
NOTICE:  If an employer did not remit the taxes and/or quarterly employee withholding tax return for the 
period(s) of the refund, the City of St. Matthews will notify you that no refund will be issued due to your 
employer’s failure to remit payment of taxes and/or failure to file the quarterly employee withholding tax 
return.  Contact your employer to resolve this problem.   
 

GENERAL INSTRUCTIONS FOR WITHHOLDING TAX REFUND 
It is imperative that the refund application be completed as required in the instructions below.   If it is not correctly completed, 
correspondence will be mailed to either the employee or employer, which will delay the refund.  
 
THERE IS A ONE-YEAR STATUTE OF LIMITATIONS within which a refund request must be submitted to the City of St. Matthews.  The 
refund request must be postmarked within one year from the date of the Annual Reconciliation (form SWM3) and W2 data is due.  
The Annual Reconciliation and W2 data is due before January 31.  
 
GENERAL INFORMATION:  
The application can be completed by the employee but must also be signed by the employer, verifying that all of the information on 
the document is correct.  The refund check will be mailed directly to the employee at the address provided on the application.  It 
takes approximately six to eight weeks to process all refund requests.   
 
REQUIRED INFORMATION NEEDED FOR THE REFUND REQUEST: 
        Separate Application for Each Employee  
        Copy of W2 Issued for Each Year Involved (If the W2 is not available, a copy of the last check stub with year to date totals 
         will suffice.) Current year withholding must also be verified.  A computer printout from the payroll office will suffice.  
        Signed by Employee and Employer 
 
INSTRUCTIONS FOR PREPARATION OR REFUND APPLICATION  
PART I:  Enter the employer’s legal name, federal identification number or SSN, and the St. Matthews account number.  
 
PART II:  Enter the year for which the refund is requested.  Enter the employee’s name, address, city, state, zip and employee’s SSN 
(required).  The check will be mailed to the address provided in this area.  Provide a brief job description.   
 
PART III: This section must be completed by anyone requesting a refund for out of town work.   NOTE:  In computing the refund 
request, gross wages (line 4, part III) should include other compensation including non-cash fringe benefits, deferred compensation 
and insurance over $50,000.  
 
Line 1: List the total number of hours worked outside St. Matthews.  This must be at least 5% of your work time, translated in work   
             hours; at least 104 hours based on 2080 hours worked per year.  This is excluding vacation, sick and holidays.  
Line 2: List the total number of hours worked per year.  This number may vary based on overtime.  
Line 3: List the percentage of time worked outside St. Matthews. (divide line 1 by line 2) 
Line 4: List the total gross wages per W2. (including deferred compensation; should be based on Medicare Wages on the W2     ) 
Line 5: List the total amount of wages earned outside of St. Matthews.  (multiply line 3 by line 4) 
Line 6: List the wages subject to occupational tax. (subtract line 5 from line 4) 
Line 7: Compute the occupational taxes due per wages listed on line 6.  (applicable tax rate = .0075) 
Line 8: List the total taxes withheld. (per W2 for the City of St. Matthews)   
Line 9: Total refund due (subtract line 7 from line 8) 
 
If any of the above information is not provided, contains a calculation error, or does not tie back to the W2 form, the refund will be 
delayed.  
 
PART IV:  This section must be completed on what type of refund is being requested.    The quarters for which the refund is being 
requested must be provided.   
 
PART V:  The employee and employer must provide a signature in order for the refund application to be processed.     
 
CERTIFICATION SIGNATURE 
The person signing these forms must be in a positon of authority (corporate officer, chief accountant or head of payroll) and must 
certify that the information provided on this statement is true and correct.  The signature must also be notarized.   
 
Please contact the City of St. Matthews at 502-895-9444 if you have any questions.