Madison County Finance Office                      How to reconcile your Payroll Witholdings
   RECONCILIATION OF LICENSE FEE WITHHELD           Enter under TOTAL PAYROLL the total of all payroll jurisdictions for each quarter. Enter 
                                                    under SUBJECT PAYROLL the quartley total of all employees for services within Madison 
           DURING YEAR ENDED                        County, but outside the city limits of Richmond or Berea. All comensation, i.e., Vacation, 
* PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS* Sick and Holiday Pay is to be included in the payroll totals.
                                     Total Payroll    Subject Payroll                             Total Payroll Witholdings
1.  1st Quarter ended March 31     $                $                                      x 1% = $
2.  2nd Quarter ended June 30      $                $                                      x 1% = $
3.  3rd Quarter ended September 30 $                $                                      x 1% = $
4.  4th Quarter ended December 31  $                $                                      x 1% = $
5.  TOTAL ALL QUARTERS             $                $                                      x 1% = $
6. Acutal witholding payments made quarterly on Occupational Tax Form …………………………………….
7. Difference between lines 5 and 6 (if any, check applicable block below) …………………………………..
8. Number of Employees _________    Signature ________________________________ Title ______________  Date _________________

   Account Number                                                              *           Any balance is due 12/31 to avoid penalties
   Federal ID                                                                              Any overpayment is to be:
   Phone Number                                                                            Credited to next quarter

                                                                               Please enclose W-2's or listing of Employee Wages
                                   To Be Filed With The 4th Quarter's Return By January 31                          MR_REC 9/26/2006