CITY OF OWENSBORO                                                              FORM - REC
    EMPLOYERS' ANNUAL RECONCILIATION OF                                                                 For Year Ended

                  LICENSE FEE WITHHELD
                              Print Name & Address of Employer                                          Account #

                                                                                                        Social Security# or
                                                                                                        Federal ID #

                              Part I   WITHHOLDING PAYMENT SCHEDULE

Jan                           April               July                                          Oct

Feb                           May                 Aug                                           Nov
March or                      June or             Sept or                                       Dec or 
1st Qtr                       2nd Qtr             3rd Qtr                                       4th Qtr

         Number of Employees:                                                      Total Payments      $

SEE INSTRUCTIONS                                  Part II   LICENSE FEE COMPUTATION
        NOTE:            1)  Total Wages, Tips, Other Compensation per Box 1 of Federal
                              Form W-2 or W-3
Copies of Federal        2)  Add Deferred Compensation Contributed by Employees
Forms W-2 and W-3, 
    along with an        3)  Add Employee Elections made under Section 125 of the Internal Revenue  
Employee Benefit              Code, plus other subject Welfare, Fringe and Benefit Plan Payments
listing if required; or 
                         4)  Total Gross Compensation (Add Lines 1 through Line 3)
a Detailed Employee 
Listing with the         5)  Less Total Gross Compensation Paid for Service Outside 
Required Equivalent           the City of Owensboro and Other Compensation not Subject.
Information must be 
submitted with this      6) Taxable Compensation (Subtract Line 5 from Line 4)
        form.
                         7) Occupational License Fee (Line 6 X 1.33%)

Due: February 28
                         8) Total Employee License Fee Remitted During Year ( From Part I) 

REMIT & MAKE             9)  If Line 7 is greater than Line 8, Enter Difference as License Fee Due 
    PAYMENT TO:               (Attach separate sheet identifying period(s) underpayment occurred)
OCCUPATIONAL TAX        10)  Penalty @ 5% per calendar month or portion thereof not to exceed 25%. 
ADMINISTRATOR                  Minimum $25 
    PO BOX 10008
OWENSBORO, KY           11)  Interest @ 1% per calendar month or portion thereof, from Due Date
    42302-9008
                        12) TOTAL AMOUNT DUE (Add Lines 9, 10 and 11)

Phone: (270) 687-5600   13)  If Line 8 is greater than Line 7, Enter Difference as Overpayment

www.owensboro.org       (To claim refund of Overpayment, Amended Returns must be filed for periods in error) 
RETURN MUST BE SIGNED - I hereby certify, under penalty of perjury, that the statements made herein and in any supporting schedules are true, 
correct, and complete to the best of my knowledge.

                                                                                      (       )     -
    SIGNATURE                         TITLE       DATE                             PHONE

             DAVIESS COUNTY FISCAL COURT                                                             FORM - REC
    EMPLOYERS' ANNUAL RECONCILIATION OF                                                               For Year Ended

                  LICENSE FEE WITHHELD
                              Print Name & Address of Employer                                        Account #

                                                                                                      Social Security# or
                                                                                                      Federal ID #

                              Part I   WITHHOLDING PAYMENT SCHEDULE

Jan                           April               July                                        Oct

Feb                           May                 Aug                                         Nov
March or                      June or             Sept or                                     Dec or 
1st Qtr                       2nd Qtr             3rd Qtr                                     4th Qtr

         Number of Employees:                                                      Total Payments    $
SEE INSTRUCTIONS                                  Part II  LICENSE FEE COMPUTATION
        NOTE:            1)  Total Wages, Tips, Other Compensation per Box 1 of Federal
                              Form W-2 or W-3 
Copies of Federal 
                         2)  Add Deferred Compensation Contributed by Employees 
Forms W-2 and W-3, 
    along with an        3)  Add Employee Elections made under Section 125 of the Internal Revenue   
Employee Benefit              Code, plus other subject Welfare, Fringe and Benefit Plan Payments
listing if required; or 
a Detailed Employee      4)  Total Gross Compensation (Add Lines 1 through Line 3)
Listing with the 
                         5)  Less Total Gross Compensation Paid for Service Outside 
Required Equivalent 
                              Daviess County and Other Compensation not Subject.
Information must be 
submitted with this      6) Taxable Compensation (Subtract Line 5 from Line 4)
        form.
                         7) Occupational License Fee (Line 6 X .35%)

Due: February 28         8) Total Employee License Fee Remitted During Year (From Part I)

    REMIT & MAKE         9)  If Line 7 is greater than Line 8, Enter Difference as License Fee Due 
    PAYMENT TO:               (Attach separate sheet identifying period(s) underpayment occurred) 
OCCUPATIONAL TAX        10)  Penalty @ 5% per calendar month or portion thereof not to exceed 25%. 
ADMINISTRATOR                  Minimum $25 
    PO BOX 10008
OWENSBORO, KY           11)  Interest @ 1% per calendar month or portion thereof, from Due Date
    42302-9008
                        12)  TOTAL AMOUNT DUE (Add Lines 9, 10 and 11) 
Phone: (270) 687-5600   13)  If Line 8 is greater than Line 7, Enter Difference as Overpayment

www.owensboro.org       (To claim refund of Overpayment, Amended Returns must be filed for periods in error) 
RETURN MUST BE SIGNED - I hereby certify, under penalty of perjury, that the statements made herein and in any supporting schedules are true, 
correct, and complete to the best of my knowledge.

                                                                                     (      )    -
    SIGNATURE                         TITLE       DATE                             PHONE #