CITY OF OWENSBORO/DAVIESS COUNTY FISCAL COURT                                                        FORM 1099 ST 
      SUMMARY AND TRANSMITTAL OF                                                                  
       NON-EMPLOYEE EARNINGS                                                 YEAR                 
     100% City of Owensboro                                        ACCOUNT NUMBER    
                                                                                     
      100% Daviess County 
                                   
  MAIL TO: OCCUPATIONAL TAX ADMINISTRATOR                      
                     PO BOX 10008                                   Phone:  (270) 687-5600 
                     OWENSBORO, KY 42302-9008                           Fax:  (270) 687-8526           
 
                                                       INSTRUCTIONS: 
  Licensees making payments of $600 or more to recipients other than employees, (i.e., non-employee compensation payments) for 
  services performed or rents paid on property located within the City of Owensboro and/or Daviess County are responsible to maintain 
  records of those payments.  The licensee making payment will be responsible for completing Form 1099-ST and submitting it to the 
  Occupational Tax Administrator by February 28 of the year following the close of the calendar year in which the non-employee 
  compensation was paid. Businesses that make subject payments, where all monies reported over $600 were paid to recipients for work 
  performed 100% within the City Limits of Owensboro or 100% within Daviess County, outside the City of Owensboro, may comply 
  with the reporting requirement by checking the appropriate “100%” box on Form 1099-ST (see above), and submitting copies of 
  Federal Form 1099 MISC. (Completion of Columns 1 through 5 of Form 1099-ST  not  required if the licensee is eligible to submit 
  1099MISC, unless payment is made to an entity not requiring the completion of a Federal Form 1099 MISC, such as payments to 
  corporations.)  
                   RETURN THIS PAGE WITH NON-EMPLOYEE INFORMATION 
                                                                              
      Column 1                     Column 2            Column 3                      Column 4                      Column 5 
    Name and Address of  each     Social Security No.   Total                      Non-Employee                    Non-Employee 
 Non-Employee receiving           or Federal I.D. No.   Compensation Paid to  Compensation  from                   Compensation from 
   compensation                   for  each Non-       each Non-Employee             Column 3,                     Column 3,  for Work 
                                   Employee                                   for Work Performed                   Performed within Daviess 
                                                                                     within the                    County (Outside the City 
                                                                              City of Owensboro                    of Owensboro) 
                                                                                                                          
    Preparer’s Signature _____________________________________                Preparer’s Phone___________________________________                                                         
         
                                                                                         CONTINUED ON BACK                                                                        
 

 Column 1                     Column 2            Column 3              Column 4           Column 5 
    Name and Address of  each Social Security No. Total                 Non-Employee       Non-Employee 
 Non-Employee receiving       or Federal I.D. No.  Compensation Paid to Compensation, from Compensation, from 
 compensation                 for  each Non-      each Non-Employee     Column 3,          Column 3,  for Work 
                              Employee                                  for Work Performed Performed within Daviess 
                                                                        within the         County (Outside the City 
                                                                        City of Owensboro  of Owensboro) 
                                                                                                  
                                                                        ATTACH ADDITIONAL SHEET IF NECESSARY