• EMPLOYER, NOT PREPARER, IS RESPONSIBLE FOR ALL                 OFFICE USE ONLY (DO NOT WRITE IN THIS SPACE)
                   INFORMATION AND PAYMENTS.  
                 • SEE BACK FOR FILING INSTRUCTIONS                                        ADJ      ADT PrintW2     FormCT1A   EL
                 • QUESTIONS OR ASSISTANCE CALL (859)392-1440 
                 • DO NOT STAPLE THIS FORM OR ATTACHMENTS                         PI           OV       RAE           TERM    UND              APP
                 REMIT WITH PAYMENT TO:                REMIT WITHOUT PAYMENT TO: 
                  KENTON COUNTY FISCAL COURT   KENTON COUNTY FISCAL COURT         ACCOUNT NUMBER                 YEAR QUARTER             DUE DATE
                  PO BOX 706237                            PO BOX 792 
                  CINCINNATI  OH  45270                      COVINGTON   KY  41012
KENTON COUNTY & CITIES, KENTUCKY 
EMPLOYEE'S QUARTERLY WITHHOLDING                                                  I DECLARE UNDER PENALTY OF PERJURY THAT THIS RETURN HAS 
FORM QCC1 - REV 6/2021                                                            BEEN EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND 
DBA, Name & Mailing Address:                                                      BELIEF IS TRUE, CORRECT AND A COMPLETE RETURN.

                                                                                                    SIGNATURE REQUIRED                         DATE

                                                                                           PRINT NAME                  TELEPHONE                   TITLE

                                                                                               FEDERAL IDENTIFICATION OR SOCIAL SECURITY NUMBER
COLUMN 1           COLUMN 2            COLUMN 3                       COLUMN 4             COLUMN 5     COLUMN 6      COLUMN 7 COLUMN 8            COLUMN 9 
 COUNTY & CITY     TOTAL EARNINGS      EXCLUDED                       SUBJECT              WITHHOLDING  FEE DUE        PENALTY INTEREST            TOTAL FEE 
                                       EARNINGS                       EARNINGS             RATE                                                    DUE
KENTON COUNTY 
UNDER $25,000
KENTON COUNTY 
OVER $25,000
BROMLEY
CRESCENT SPRINGS
CRESTVIEW HILLS
EDGEWOOD
ELSMERE
ERLANGER
FORT MITCHELL
FORT WRIGHT
INDEPENDENCE
LAKESIDE PARK
LUDLOW
PARK HILLS
RYLAND HEIGHTS
TAYLOR MILL
VILLA HILLS
                                                                                           TOTAL:
EMPLOYEE LIST          EXCLUDED EMPLOYEE EARNINGS - SEE FILING INSTRUCTION                                                                TOTAL AMOUNT DUE
                                       GROSS EARNINGS                             COLUMN A          COLUMN B           COLUMN C                COLUMN D 
                                                                      EARNINGS AMOUNT OVER     EARNINGS AMOUNT OVER   EARNINGS AMOUNT IN       CITY & STATE WHERE  
EMPLOYEE NAME      SOCIAL SECURITY#    THIS QUARTER                   KENTON COUNTY MAXIMUM         CITY MAXIMUM      OTHER JURISDICTIONS       COLUMN C EARNINGS 
                                                                                                                                                  EARNED

TOTAL # EMPLOYEES
                                       TOTAL                          TOTAL                    TOTAL                  TOTAL               TOTAL