CITY OF MADISONVILLE KENTUCKY                                                           Payroll Tax Year End 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

Reconciliation of Madisonville License Fee Withheld for Calendar Year is Required.
(If you have 10 or less employees, use the space provided below or furnish copies of employee's W-2.
Larger concerns may file on listing (using the format below) or furnish W-2 copies.

Social Security Number Name of Employee        Gross Wages                             Taxable Wages Occupational Tax Withheld

                                                                                       Attach Continuation Sheet if Necessary

                                                                                       W2's are due by January 31st

                                                                                       PreparedBy                                 Date

Notice: This form must be returned whether or not you had employees during this period, under Section 110 City Code of Ordinances.