MCT FORM 5                                   MARION COUNTY
                    County Treasurer, 223 North Spalding Ave., Suite 201, Lebanon, KY 40033

                      RECONCILIATION OF MARION COUNTY OCCUPATIONAL LICENSE FEE WITHHELD
                                 FOR THE CALENDER YEAR ENDED DECEMBER 31, 2_________
                                                            (This return must be filed on or before February 28)

Employer Name____________________________________________________________________________

Address___________________________________________________________________________________

City________________________________ State______________________                                                Zip_____________________

1.  EMPLOYEE LIST (Use Continuation Sheet, MCT Form 5C for additional employees or use W-2 Forms in lieu of MCT Form 5C)
Social Security No. Name & Address of Employee            Gross Wages,                                          Wages, etc.   Occupational 
                                                          etc. Paid                                             Allocable to  License Tax
                                                                                                                Marion County Withheld

2.  TOTAL THIS PAGE…………………………………………………

3.  TOTAL ALL PAGES………………………………………………..

4.  TOTAL PAGES THIS REPORT……………………………………

5.  TOTAL NO. EMPLOYEES REPORTED………………………….

6.  QUARTERLY TOTALS (As Reported on MCT Form 6Q)
QUARTER   Gross Wages, Etc. Wages Allocable to   License Fee Payable @1%                                        Amount Remitted to City of
                            Marion County                                                                       Marion County

1st

2nd

3rd

4th

7.  TOTALS
                                                         *NOTE: TOTALS SHOULD AGREE WITH TOTALS IN ITEM NO. 3

I declare that to the best of my knowledge and belief, that all information provided herein is true, complete, and correct.

Signature                                        Date                                                           Title

Make checks payable and mail return to County Treasurer, 223 North Spalding Ave., Suite 201, Lebanon, KY  40033

MCT FORM 5C            MARION COUNTY                                                                      PAGE ____ OF ____
                    County Treasurer, 223 North Spalding Ave., Suite 201, Lebanon, KY 40033

                       CONTINUATION FOR RECONCILIATION OF MARION COUNTY OCCUPATIONAL
                                                           LICENSE FEE WITHHELD

CONTINUED EMPLOYEE LIST
Social Security No. Name & Address of Employee                                 Gross Wages, Wages, etc.   Occupational
                                                                               etc. Paid    Allocable to  License Tax
                                                                                            Marion County Withheld

TOTALS THIS PAGE…………………………………………………..