EASTERN KENTUCKY UNIVERSITY Richmond, Kentucky 40475 OCCUPATIONAL LICENSE FEE (CITY TAX) EXEMPTION FORM

Purpose:  To claim full or partial exemption from Richmond, KY withholding tax on wages paid by EKU. Qualifications for exemption:  If you WORK assignment if not geographically located in Richmond, you will be eligible for exemption from Richmond Occupational Tax. You cannot claim exemption from Richmond city tax based on where you live - exemption is derived from work address. Duration:  This form if effective only for current calendar year. No refunds will be processed for forms received in payroll after January 15th for the applicable calendar year! Employee Section:  Under a penalty of law, I declare that to the best of my knowledge this is true, correct, and complete document. Additionally, I realize it is my responsibility to notify the payroll office of any change in my status during the calendar year.

Note:  If you work at multiple sites, file a separate form for each work site. The total of all should = 100%.

Work Address:
	Geographical location (P.O. Boxes are not acceptable)
	City	State	Zip Code

Percent of time at this work (based on 10 day work period)
If work location is within city limits, list city		And list county
Is your home address: Within this locality city limits?	Y N	If not, list county

Home Address:
	Street
	City	State	Zip Code

Calendar Year Effective
Printed Name:		Signature:
Social Security#:		Date:
RETURN THIS COMPLETED FORM TO:		EKU Payroll Office 521 Lancaster Avenue, CPO 24A Richmond, KY 40475-3102
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