CITY OF MADISONVILLE KENTUCKY                                                                  Payroll Tax Return
1. Total Number of Employees ____________ Taxable Employees _____________              Make Check Payable & Mail to:
2. Total Salaries, Wages, Commissions and Other Compensation __________.___ Director of Finance
3. Less Compensation Paid for Services Outside of Madisonville     __________.___ P.O. Box 1270
4. Taxable Earnings (Line 2 Minus Line 3                     __________.___ Madisonville KY  42431
5. Actual Tax Due in Period at 1.5%                          __________.___            I hereby certify that the information and
6. Adjustments from Prior Periods                            __________.___            statements contained herein and any schedules
7. Interest (1% Per Month) After Due Date                    __________.___            or exhibits attached are true and correct.
8. Penalty (5% Per Month up to 25%, $25 Min.) After Due Date __________.___             
9. Total Taxes Due Including Interest & Penalty              __________.___             
*If no wages were paid this period, mark "NONE" and return this form with explanation.  Signed                                    Date
                                                                                        
                                                                                       Date Received
                                                                                       Check Number
                                                                                       Check Amount
                                                                                       Account Number
                                                                                       For Period Ending
                                                                                       Due On or Before
Notice: This form must be returned whether or not you had employees during this period, under Section 110 City Code of Ordinances.