DAVIESS                                                                                                                                                      COUNTY         Column B

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            .35% 

                                                                                                                                                                                         CITY OF                                                                                                                                                                     Column A
                                                                                                                                                                                                                                                                                                                                                      OWENSBORO 
                                                RETURN THIS FORM WITH PAYMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              1.33%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Phone                                    Title                                   Date 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        (Add Line 8 Column A  to Line 8 Column B)….
                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            I hereby certify that the information statements contained herein and any schedules or exhibits attached 
                                                                              Account No:                           Due Date:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Signature  

                                                                                                                                                                                                                                                     Period Beginning:                                 Type:                                                                         Period Ending:                                                                                                   Total Gross Wages, Salaries and Other Compensation Paid….                                                      Less: Compensation not Subject to License Fee……………….                                                       Earnings Subject to License Fee (Line 1 minus Line 2)                                                          (Include Section 125 “Cafeteria Benefits” as subject)………                                                      License Fee Rate (Daviess County Rate in Column B is                                                                .5% for periods ending 7/31/05 thru 12/31/06)……...............                                   License Fee Due  (Line 3 Multiplied by Line 4)……………..                                          Penalty (5% per month not to exceed 25%)                                                      Interest (1% per calendar month or fraction thereof)                                                  Total Amount Due ( Add Lines 5,6, and 7)………………….                                                                                                              Payment Amount 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      1.                                                                                                             2.                                                                                                                                                               3.                                                                                                                                                                                                                                                                                         4.                                                                                               5.                                                                                                                                      6.                                                   7.                                                                                                    8.                                                                                                                                                            9.                                             

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Phone: (270) 687-5600                                                                                                                                                                                                                    INSTRUCTIONS ON BACK
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                SEE
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
                                                                                                                                          City of Owensboro/Daviess County Fiscal Court                                                                                                                      Employers Return of License Fee Withheld 
         FORM E-1                                                                                                                                                                                                                                                                                                                                                                                                                                                   Make Checks Payable and Mail to:                                                                            Occupational Tax Administrator                                                                                        PO BOX 10008                                                                                        Owensboro, KY 42302-9008                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   CHANGE OF ADDRESS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               are true and correct to the best of my knowledge.                                                                                                                                                                                                                                                                                                                                                                                _______________________________________    ____________________    ______________________    _______________                                                                                                                                                    

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            the 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           outside

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     (Note: Daviess County Rate is .5% for periods ending 7/31/05 

                                                                                                                                                                                                                                                                                                                                                                          Calculate the occupational license fee due from compensation earned within 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Enter compensation paid to employees, regardless of when or where earned.                                                                                                                                                                                                                                                                                                          Enter the amount included in Line 1 which represents payment for services                                                                                                                                                                                                                                                  - Outside the corporate city limits of the City of Owensboro on Line 2 of Column A                                                                              - Outside Daviess County on Line 2 of Column B. (Should include compensation                                                           earned in the corporate limits of the City of Owensboro).                                                               - Also include other compensation not subject to license fee.                                                                                             Enter total earnings subject to license fee. (Line 1 minus Line 2 in each column).                                                                                                                         License fee rate.                                                                                                                                                                                                                                                                                                                                       Enter the license fee due. (Line 3 multiplied by Line 4 in each column).                                                                                                                                                                                                                                  Applicable percentage of penalty multiplied by Line 5. ($25 minimum) (Any licensee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Applicable percentage of interest multiplied by Line 5. (Any licensee who fails to pay                                                                                                                                                                                                                                                                                                                                                                                                                                                    Total license fee, interest and penalty due. (Add Lines 5, 6 and 7 in each column).                                                                                                                                                             Total Payment due. ( Add Line 8 Column A to Line 8 Column B and enter on Line 9)                                                                  PAY THIS AMOUNT WITH THE RETURN)

                                                            INSTRUCTIONS                                                                                                                                                                                                                                                                                                  Important Note:                                                                                               the corporate city limits of the City of Owensboro in Column A of FORM E-1. Calculate the                                                                          occupational license fee due from compensation earned in Daviess County,                                                              corporate city limits of Owensboro, in Column B of FORM E-1.                                                                                                                       LINE 1:                                                                                                                                                                                                                                                                                                                                                                           LINE 2:                                                                                                                                     performed:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              LINE 3:                                                                                                                                                                                                   LINE 4:                                                                                                                                       Thru 12/31/06.                                                                                                                                                                                            LINE 5:                                                                                                                                                                                                                                                                                                   LINE 6:                                                                                                                                                                                               who fails to file and/or pay the license fee by the due date shall pay penalty                                                                                                                 at the rate of 5% per calendar month, not to exceed 25% of the total license                                                                                                                                      fee due, however penalty will always be a minimum of $25)                                                                                                                                             LINE 7:                                                                                                                       the license fee by the due date shall pay interest at the rate of 1% per calendar                                                                                        month, or fraction thereof, of any license fee due.                                                                                                                                                                                LINE 8:                                                                                                                                                                                                                                         LINE 9:                                                                                                                                                         (
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    The occupational license fee shall be withheld on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   No withholding of the occupational license fee on employee 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                          Each employer who employs one or more individuals shall withhold the 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               The employer shall make a return and pay the license fee in accordance with 

                                                                         WHO MUST FILE –                                                                                           occupational license fee due from each employee on salaries, wages, commissions and other                                                                                              compensation for work done or services performed or rendered in the City of Owensboro and/or                  Daviess County.                                                                                                                                                                                                                                                                                                                                                       WHEN TO FILE –                                                                the following due dates:                                                                                                     a.)  Returns required to be filed monthly shall be due on or before the 15th day of the month                                                                                                      next following each monthly period, except the return for the last month of the calendar                                                                                      year, which shall be due on January 31.                                                                                                 b.)  Returns required to be filed quarterly shall be due on or before the last day of the month                                                                                          following each quarterly period.                                                                                                                                                                                                                                        OTHER SUBJECT EARNINGS –                                                                                                    compensation paid by the employer to the employee including, but not limited to:                                                                                                a.)  Deferred compensation under Sections 403(b), 401(k), or 457 of the Internal Revenue                       Code.                                                                b.)  Employee elections under Section 125 “cafeteria plans”.                                                                         c.)  Disability, sickness and accident benefits paid by the employer.                                        d.)  Vacation and/or holiday benefits                                                                               e.)  Cash and non-cash fringe benefits not otherwise exempt.                                                                                 f.)   Separation payments including an employer administered unemployment plan.                                                                                            g.)  Life insurance premium for coverage in excess of $50,000, where premiums are paid by                                                                                                         the employer.                                                                                                                                                                                                                                                                                                                                                                                                                   EXEMPT EARNINGS –                                           compensation shall be required for:                                                                                                                                                                                                                   a.) Domestic Servants                                                                                                                     b.) Ordained Minister of Religion                                                                       c.) Disability, sickness and accident benefits paid by a third party.                                    d.) Workers compensation benefits.                                                                                      e.) Unemployment benefit payments made by the State or other government agency.                                                                                        f.)  Earnings of an employee who has not yet attained age 16                                                                                                  g.) Death benefits payable by an employer to the beneficiary of an employee or to his estate.