Commonwealth of Kentucky 
                                           City of Oak Grove 
                                           P.O. Box 250 
                                 Oak Grove, Kentucky 42262-0250 
                            Phone: 270-439-4646  Fax:  270-439-1201 

                     PAYROLL MONTHLY TAX RETURN 
                                      Ordinance No. 2008-05 
  
 For Month Ending: 
  
                             TH
 PAYMENT IS DUE BY THE 30  OF THE FOLLOWING MONTH 
  
  1) Total Earnings Paid to ALL Employees (*GROSS)           $_____________________________ 

  2) Wages Earned outside of the Oak Grove City Limits       $_____________________________ 

  3) Taxable Earning (Subtract Line 2 from Line 1)           $_____________________________ 

  4) TAX DUE (Line 3 multiplied by 1.5%)                     $_____________________________ 

  5) PENALTY (**10% of line 4 ($1.00 minimum))               $_____________________________ 

  6) INTEREST (***12% per year (or 1% per month))            $_____________________________ 

  7) TOTAL PAYMENT DUE (Add Lines 4,5 & 6)                   $_____________________________ 

  PLEASE MAIL YOUR PAYMENT WITH THIS COMPLETED FORM TO THE ADDRESS ABOVE 
     If the payroll amount is zero (0), you may email this form to: sonya_lett@oakgroveky.org 
                                                    
     *If no wages were paid, write “NONE” on line one (1), sign, date and return by the due date 
           **Penalty is assessed if payment is not made to the City of Oak Grove by the due date 
     ***Interest is due at the rate of 12% per year or 1% per month on any unpaid payroll tax 

I swear (or affirm) that the information provided on this form is true and correct to the best of my knowledge 
 
Signature:______________________________________________________________________________________ 
 
Title:__________________________________________ Email Address:___________________________________ 
 
Date:____________________ Phone #:____________________ Fax #:_____________________________________