COMMONWEALTH OF KENTUCKY 
                                            CITY OF OAK GROVE 
                                                 P.O. BOX 250 
                            OAK GROVE, KENTUCKY 42262-0250  
                                                            
                            PH (270) 439-4646    FAX: (270) 439-1201 
 
                        PAYROLL QUARTERLY TAX RETURN 
                                          Ordinance No. 2008-05 
              
FOR QUARTER ENDING:                                                                                               
                                                 ST           ND                  RD                    TH
                                             1  QTR      2  QTR      3  QTR            4  QTR                      
 
PAYMENT DUE BY THE 30 THDAY OF THE FOLLOWING MONTH. 
 
1. TOTAL earnings paid to all employees (*GROSS)                                     $______________________________________ 

2. Wages earned outside OAK GROVE city limits                 $______________________________________ 

3. Taxable earnings (Line 1 minus Line 2)                     $______________________________________ 

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)                     $______________________________________ 

        MAIL YOUR PAYMENT WITH THIS COMPLETED FORM TO THE ADDRESS ABOVE 

  * If no wages are paid for this month, write “NONE” on line 1, sign, and date and return this form 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: _______________________________________________________________________________ 
  
 Date: _______________________________________________________________________________ 
  
 Phone Number _________________________________Fax Number___________________________