CITY OF OWENSBORO AND DAVIESS COUNTY FISCAL COURT                            (FOR PERIODS ENDING AFTER
EMPLOYER'S AMENDED RETURN OF LICENSE FEE WITHHELD                            6/30/17 ONLY)

         NAME, ADDRESS AND PHONE NUMBER                                      Account No:

                                                                             Period Beginning:
                                                                             Period Ending:
                                                                             Due Date:

PART I (COMPLETE PART II ON BACK)
                                                      As Originally          Net Change                       
WAGE INFORMATION:  FROM FORM E-1                      Reported or Adjusted   Increase or Decrease             Correct Amount

TOTAL GROSS WAGES, SALARIES AND OTHER
         COMPENSATION PAID:
   1A.  City of Owensboro

   1B.  Daviess County
LESS COMPENSATION NOT SUBJECT TO LICENSE FEE:
   2A.  City of Owensboro

   2B.  Daviess County
        EARNINGS SUBJECT TO LICENSE FEE:
   3A.  City of Owensboro (Line 1A minus Line 2A)

   3B.  Daviess County (Line 1B minus Line 2B)
                      LICENSEE FEE DUE:
   4A.  City of Owensboro (1.78% of Line 3A)

   4B.  Daviess County (.35% of Line 3B)
PENALTY:  (5% per calendar month not to exceed 25%,
                                   $25 minimum)
   5A.  City of Owensboro

   5B.  Daviess County
INTEREST:  (1% per calendar month or fraction thereof)
   6A.  City of Owensboro

   6B.  Daviess County
         TOTAL AMOUNT DUE:
   7A.  City of Owensboro (Add Lines 4A, 5A and 6A)

   7B.  Daviess County (Add Lines 4B, 5B and 6B)

PAYMENTS
         LICENSEE FEE, INTEREST AND PENALTY PAID WITH ORIGINAL RETURN:
   8A.  City of Owensboro

   8B.  Daviess County
                      PAYMENTS NOT CLAIMED ON THE ORIGINAL RETURN:
   9A.  City of Owensboro

   9B.  Daviess County
                      TOTAL PAYMENTS:
   10A.  City of Owensboro (Line 8A plus 9A)

   10B.  Daviess County (Line 8B plus Line 9B)

REFUND OR AMOUNT DUE
REFUND, IF ANY, SHOWN ON ORIGINAL RETURN:
   11A.  City of Owensboro

   11B.  Daviess County
       TOTAL ADJUSTED PAYMENTS:
   12A.  City of Owensboro (Line 10A minus Line 11A)

   12B.  Daviess County (Line 10B minus Line 11B)
       TOTAL AMOUNT DUE:
   13A.  City of Owensboro:  If Line 7A of Column III is more than 12A, enter the amount due

   13B.  Daviess County:  If Line 7B of Column III is more than Line 12B, enter the amount due
       TOTAL REFUND DUE:
   14A.  City of Owensboro:  If Line 7A of Column III is less than Line 12A, enter the refund due

   14B.  Daviess County:  If Line 7B of Column III is less than Line 12B, enter the refund due

PART II

Give a brief explanation why this amended return is being filed.

I, the undersigned, declare under penalties of perjury that I have examined this return, including all accompanying schedules 
and statements, and to the best of my knowledge and belief, it is true, correct and complete.

Signature and Phone Number of Preparer                          Date                         Signature of License Fee Payer

STATUE OF LIMITATIONS
No refund shall be made on a filed return two (2) years after the date the overpayment is made.

                                                 MAIL TO:    OCCUPATIONAL TAX ADMINISTRATOR
                                                             PO BOX 10008
                                                             OWENSBORO KY  42302-9008
                                                             TELEPHONE NUMBER:  (270) 687-5600

INSTRUCTIONS:

PART I

Line 1A      City of Owensboro
                 Column I – Enter Gross wages, Salaries and other Compensation as originally reported on Form E-1.
                 Column III – Enter Gross wages, Salaries and other Compensation as amended.
                 Column II – Enter the net increase or decrease of gross wages, salaries and other compensation.

Line 1B     Daviess County
            Column I – Enter Gross wages, Salaries and other Compensation as originally reported on Form E-1.
            Column III – Enter Gross wages, Salaries and other Compensation as amended.
            Column II – Enter the net increase or decrease of gross wages, salaries and other compensation.

Line 2A      City of Owensboro
            Column I- Enter compensation not subject to the license fee as originally reported on Form E-1.
            Column III- Enter compensation not subject to the license fee as amended.
            Column II - Enter the net increase or decrease of compensation not subject to the license fee.

Line 2B      Daviess County
            Column I- Enter compensation not subject to the license fee as originally reported on Form E-1.
            Column III- Enter compensation not subject to the license fee as amended.
            Column II - Enter the net increase or decrease of compensation not subject to the license fee.

Line 3A      City of Owensboro
            Column I – Enter earnings subject to license fee as originally reported. Line 1A minus Line 2A.
            Column III – Enter earnings subject to license fee as amended. Line 1A minus Line 2A.
            Column II – Enter the net increase or decrease of earnings subject to the license fee.

Line 3B      Daviess County
            Column I – Enter earnings subject to license fee as originally reported. Line 1B minus Line 2B.
            Column III – Enter earnings subject to license fee as amended. Line 1B minus Line 2B.
            Column II – Enter the net increase or decrease of earnings subject to the license fee.

Line 4A     City of Owensboro
            Column I – Enter license fee due as originally reported.
            Column III – Enter license fee due as amended. Multiply Line 3A by 1.78%.
            Column II – Enter the net increase or decrease of license fee due.

Line 4B      Daviess County
            Column I – Enter license fee due as originally reported.
            Column III – Enter license fee due as amended. Multiply Line 3A by 0.35%.
            Column II – Enter the net increase or decrease of license fee due.

Line 5A      City of Owensboro
            Column I – Enter penalty as originally reported.  Any licensee 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, the penalty will 
            always be a minimum of $25. Multiply applicable percentage by Line 4A.
            Column III – Enter penalty due on the amended license fee due. Any licensee 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, the 
            penalty will always be a minimum of $25. Multiply applicable percentage by Line 4A.
            Column II – Enter the net increase or decrease of penalty. 

Line 5B     Daviess County

            Column I – Enter penalty as originally reported.  Any licensee 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, the penalty will 
            always be a minimum of $25. Multiply applicable percentage by Line 4B.
            Column III – Enter penalty due on the amended license fee due. Any licensee 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, the 
            penalty will always be a minimum of $25. Multiply applicable percentage by Line 4B.
            Column II – Enter the net increase or decrease of penalty.

Line 6A      City of Owensboro
            Column I – Enter interest as originally reported. Any licensee who fails to pay 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. Multiply Line 4A by applicable percentage.
            Column III – Enter interest due on the amended license fee due. Any licensee who fails to pay 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.  Multiply Line 4A by 
            applicable percentage.
            Column II – Enter the net increase or decrease of interest.

Line 6B      Daviess County
            Column I – Enter interest as originally reported. Any licensee who fails to pay 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. Multiply Line 4B by applicable percentage.
            Column III – Enter interest due on the amended license fee due. Any licensee who fails to pay 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.  Multiply Line 4B by 
            applicable percentage.
            Column II – Enter the net increase or decrease of interest.

Line 7A      City of Owensboro
            Column I – Enter total amount due as originally reported.  Add Lines 4A, 5A and 6A.
            Column III – Enter total amount due as amended. Add Lines 4A, 5A and 6A.
            Column II – Enter the net increase or decrease of the total amount due.

Line 7B      Daviess County
            Column I – Enter total amount due as originally reported.  Add Lines 4B, 5B and 6B.
            Column III – Enter total amount due as amended. Add Lines 4B, 5B and 6B.
            Column II – Enter the net increase or decrease of the total amount due.

Line 8A      City of Owensboro – Enter the amount of license fee, interest and penalty paid with original return.

Line 8B      Daviess County – Enter the amount of license fee, interest and penalty paid with the original return.

Line 9A      City of Owensboro – Enter any existing payments or credits not claimed on the original return.

Line 9B      Daviess County – Enter any existing payments not claimed on the original return.

Line 10A    City of Owensboro – Enter total payments. Line 8A plus Line 9A.

Line 10B    Daviess County – Enter total payments. Line 8B plus Line 9B.

Line 11A    City of Owensboro – Enter refund, if any, shown on original return.

Line 11B    Daviess County – Enter refund, if any, shown on original return.

Line 12A    City of Owensboro – Enter adjusted payments. Line 10A minus Line 11A.

Line 12B    Daviess County – Enter adjusted payments. Line 10B minus Line 11B.

Line 13A    City of Owensboro – If Line 7A of Column III is more than Line 12A, enter the amount due.

Line 13B    Daviess County – If Line 7B of Column III is more than Line 12B, enter the amount due.

Line 14A    City of Owensboro– If Line 7A of Column III is less than Line 12A, enter the refund due. No refund is issued under $5.00.

Line 14B    Daviess County – If Line 7B of Column III is less than Line 12B, enter the refund due.  No refund is issued under $5.00.

PART II

Give a brief explanation why the amended return is being filed.