Form 211-65 - Application For Refund For Persons 65 Years Or Over - 2007
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1OFFICE USE ONLY
2007
Form 211-65
VCH#
_______________________
ACCT#
______________________
APPLICATION FOR REFUND
______________
____________
INITIALS
DATE
FOR PERSONS 65 YEARS OR OVER
If your refund claim is for wages earned outside Fayette County
or unreimbursed expenses, you must use Form 211-22.
APPLICANT’S SOCIAL SECURITY NO. __________________________
NAME ____________________________________________________
EMPLOYED BY____________________________________________________
ADDRESS__________________________________________________
ADDRESS________________________________________________________
__________________________________________________
_______________________________________________________
DAYTIME TELEPHONE NO. (__________)_______________________
______________________________________________________
DATE OF BIRTH ___________________________________________
MONTH/DAY/YEAR
______________________________________________________________________________________________________________________________
FOR OFFICE USE
ONLY
1
TOTAL 2007 GROSS 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
- WHICHEVER IS LESS
$68
…
ENTER
OR AMOUNT OF WITHHOLDING
* PROCESSING WILL BEGIN AFTER FEBRUARY 15, 2008 *
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
______________________________________________________________________________________________________________________________
2007 REFUND INSTRUCTIONS
Line 1:
Enter the “Total Gross Compensation”, the amount before any deductions, for 2007. This includes 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
I:/TAXDATA/TAXFORMS/2007/211-65.DOC
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