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:        $
                                                  Part II   LICENSE FEE COMPUTATION
    SEE INSTRUCTIONS       1)Total Wages, Tips, Other Compensation per Box 1 of Federal
         NOTE:                Form W-2 or W-3

                           2)Add Deferred Compensation Contributed by Employees

    Copies of Federal      3)Add Employee Elections made under Section 125 of the Internal Revenue
    Forms W-2 and W-3,        Code, plus other subject Welfare, Fringe and Benefit Plan Payments
         along with an
    Employee Benefit       4)Total Gross Compensation (Add Lines 1 through Line 3)
    listing if required; or
    a Detailed Employee    5)Less Total Gross Compensation Paid for Service Outside
         Listing with the     the City of Owensboro and Other Compensation not Subject.
    Required Equivalent
    Information must be    6)Taxable Compensation (Subtract Line 5 from Line 4)
    submitted with this 
         form.             7)Occupational License Fee (Please see instructions for rate)

    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:    $
                                                             Part II   LICENSE FEE COMPUTATION
    SEE INSTRUCTIONS       1) Total Wages, Tips, Other Compensation per Box 1 of Federal
         NOTE:                  Form W-2 or W-3

                           2) Add Deferred Compensation Contributed by Employees

    Copies of Federal      3) Add Employee Elections made under Section 125 of the Internal Revenue
    Forms W-2 and W-3,          Code, plus other subject Welfare, Fringe and Benefit Plan Payments
         along with an
    Employee Benefit       4) Total Gross Compensation (Add Lines 1 through Line 3)
    listing if required; or
    a Detailed Employee    5) Less Total Gross Compensation Paid for Service Outside
         Listing with the       Daviess County and Other Compensation not Subject.
    Required Equivalent
    Information must be    6) Taxable Compensation (Subtract Line 5 from Line 4)
    submitted with this 
         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