Lincoln County Occupational Tax Services
                                                102 E Main Street, Ste 3, Stanford, KY 40484 * (606) 365-4520 
                                                                  www.lincolnky.com

                                                EMPLOYERS QUARTERLY RETURN OF LICENSE FEE
                                            (NOTE: This original must be filled out and returned to Lincoln County. Please save a copy for your personal records.)
                                                                                CALENDAR YEAR

        ACCOUNT NUMBER                                            QUARTER ENDING                                                                                                DUE DATE

Business Name:                                                                      Federal ID/SS #:
Address:                                                                            Phone # :
Address:
City/State/Zip:                                                                                    Check here for address changes.

INSTRUCTIONS: If this is a 1st, 2nd, 3rd or 4th Quarter return, please fill out section 1 below.
For the Annual Reconciliation, please fill out section 2 below.
SECTION 1. QUARTERLY RETURN FOR QUARTERS 1, 2, 3, and 4

Total salaries, wages, commissions, and other                   1 Gross wages                                                                                     $
compensation paid.
                                                                2 Less wages earned outside Lincoln County                                                        $

This quarterly  return  must  be  remitted  to  Lincoln         3 Total Lincoln County taxable wages                                                              $
County EVEN IF THERE ARE NO WAGES TO REPORT!
Non filers will be subject to penalty.                          4 Total tax due (line 3 x 1%)                                                                     $

                                                                5 Penalty (Minimum of $25 or 5% per month not to exceed 25%) $

                                                                6 Interest (1% per month)                                                                         $

                  Required                                                                            TOTAL:                                                      $
        Number of Employees:
                                                                                For Quarter Ending (Circle One):                                                  3/31   6/30   9/30    12/31
                                                                                                      Due Date:                                                   4/30   7/31   10/31   1/31

SECTION 2. ANNUAL RECONCILIATION and W-2 W-3 FORMS/     DUE 2/28

This annual             Payments Remitted                       1 Gross wages (per W-2's)                                                                         $
reconciliation          (excluding penalties & interest)
must be                                                         2 Less wages earned outside Lincoln County                                                        $
submitted to the        1Q $
Lincoln County                                                  3 Total Lincoln County taxable wages                                                              $
Tax Administrator       2Q $
even if there are                                               4 Total tax due (line 3 x 1%)                                                                     $
NO wages to report.     3Q $
                                                                5 Less total already remitted (Total from left)                                                   $ (                        )
                        4Q $
                                                                6                   Sub-Total of Balance Due :                                                    $
                  Total   $                                     7 Penalty (Minimum of $25 or 5% per month not to exceed 25%) $

                                                                8 Interest  (1% per month)                                                                        $

                                                                                                      Balance Due:                                                $
                    Please make sure to include W-2 and W-3 forms with this reconciliation!

                                                                  Please remit to:                                                                                For Official Use Only
Signature:                                                                      Lincoln County                                                                    Date Received:
                                                                                Tax Administrator                                                                 Check #       Amount Paid
Date:                             /             /                 102 E Main Street, Ste 3         
                                                                  Stanford, KY 40484

           I declare, under the penalties of perjury, that this return has been examined, and to the best of my knowledge, is a true, correct, and complete return.