Louisville Metro Revenue Commission                      Do Not Duplex Form                                               
                                                                                                       
            Annual Reconciliation of Employers Quarterly Return                                        
                                                                                                                                             
            of Occupational License Fees Withheld & Schedule of                                                        W-3_2018_V1.0 
            Employees’ Wages                                                                                                           Form W-3 
  ▼     INDIVIDUAL/ SOLE PROPRIETOR     ▼                                       
  Last name                                                                     First name                MI                Social Security Number 
                                                                                                                       
  ▼     CORPORATION/ PARTNERSHIP        ▼                                       
  Legal name/ Business name                                                                                                 Federal ID Number 
                                                                                                                       
  Address (number and street)                                                              Unit/Apt. no.                          Account ID 
                                                                                                                       
  City, town, or post office                                         State                 Zip code                                    Year 
                                                                                                                       
  Email                                                              Phone no.             Ext.                         W-2’s filed electronically with 
                                                                                                                        the Revenue Commission 
  Quarterly                                 Quarter Ending                                                 Amount that should have been paid 
  Reporting     1.           March 31st                                                                    
                2.           June 30th                                                                     
                3.           September 30th                                                                
                4.           December 31st                                                                 
  Additional    5.           Total Quarterly Taxes that should have been paid (Sum of lines 1-4)           
                6.           Total Taxes withheld per Schedule of Employees’ Wages attached                
  Tax Due 
                7.           Difference between Line 5 & Line 6                                            
  Calculations 

  Signature     I hereby certify, under penalty of perjury, that the information provided and the attached supporting schedules are true, 
                correct, and complete to the best of my knowledge. 
                Your signature                                                                                              Date 
                                                                                                
                Print/Type your name                                        Your Title                                 Daytime phone number 
                                                                                                                       
                Print/Type preparer’s name   Preparer’s signature                                Date                  PTIN 
  Preparer 
                                                                                                                       
  Use Only 
                Firm’s name         ▶                                                                                  Firm’s EIN ▶    
                Firm’s address ▶                                                                                       Phone no. ▶     
 
                                                                            IMPORTANT 
  
  NO REFUNDS OR CREDITS WILL RESULT FROM ENTRIES MADE ON THIS FORM. AN AMENDED FORM W-1 MUST BE SUBMITTED TO OBTAIN 
                                             REFUNDS OR APPLIED CREDITS. 
  
  ELECTRONIC FILING: Register for electronic filing. It is an easy, secure, and convenient way to file and pay taxes on-line. For more information 
                                            log on to https://www.metrorevenue.org 

                              MAILING ADDRESS: P.O. BOX 32300, LOUISVILLE, KENTUCKY 40232-2300 
                                                                     Telephone: (502) 574-4860 

  Form W-3                                                                             Page 2 
                                Schedule of Employees’ Wages 
  If Employee W-2 Forms are not reported electronically, Form W-3 must be accompanied with W-2 copies or a Schedule of Employees’ Wages. 
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
           Last name            First name  MI  Social Security  Gross Pay             Occupational Tax 
                                                Number                                 Withheld 
                                                                                       
           Address and ZIP code                                                        
  
                                                          TOTAL                        
 
                     MAILING ADDRESS: P.O. BOX 32300, LOUISVILLE, KENTUCKY 40232-2300 
                                Telephone: (502) 574-4860