ANNUAL RECONCILIATION OF OCCUPATIONAL LICENSE FEES WITHHELD 
                       For the Year Ended December 31, ________ 
 
Check if Address Has Changed ____            Federal ID No.______________          Account # _______________ 
Business Name _________________________________________________                    Phone: (        )          -  
Address __________________________________        City________________             State_______   Zip ________ 
__________________________________________________________________________________________ 
 
1.  Total Gross Wages and Other Compensation Paid during the Year                  $ _______________ 

2.  Less Compensation Paid for Services Performed Outside Nicholasville            $ _______________ 

3.  Taxable Compensation (line 1 minus line 2)                                     $ _______________ 

4.  License Fee Due  (line 3 x 1.5%)                                               $ _______________ 

5.  License Fees Remitted with Quarterly Returns: 
                                       st
 A.  Quarter Ended March 31                       _______________ 
                                     th
 B.  Quarter Ended June 30                        _______________ 
                                         th
 C.  Quarter Ended September 30                   _______________ 
                                         st
 D.  Quarter Ended December 31                    _______________ 
           Total Fees Remitted (lines A thru D)                                    $ _______________ 
 
6. Difference (Line 4 minus line 5)-If any, check applicable box below             $ _______________ 
 
       Minor difference due to fractional variations only   -- No adjustment needed                               
       Difference indicates an underpayment   -- Payment enclosed 
       Difference indicates an overpayment   -- An amended return for the period overpaid must be filed  
       separately with a letter of explanation. 
__________________________________________________________________________________________ 
 
7.  License Fees Due (from line 4 above)                                           $ _______________ 
 
8.  Actual License Fees Withheld per Box 19 of W-2’s                               $ _______________ 
 
9.  Difference (line 7 minus line 8)-Please attach explanation of any difference   $ _______________ 
__________________________________________________________________________________________ 
 
The original of this reconciliation along with a copy of the W-2’s must be filed with the City of Nicholasville on or 
            th
before February 28  to the following address:    
           City of Nicholasville, P.O. Box 590, Nicholasville, KY  40340-0590 
           Telephone: (859) 885-7618  Fax (859) 885-9476 
 
I hereby certify that this information is true and correct to the best of my knowledge. 
 
Signature                                                              Date                                        
 
Print Name                                                             Title 

C:\Documents and Settings\acampbell\Local Settings\Temporary Internet Files\OLK13A\annual reconciliation - payroll tax.docRevised 7/11/13