(For Periods Ending After 
         City of Owensboro/Daviess County Fiscal Court                                                    6/30/17 Only)

         Form E-1 Employer Return of License Fee Withheld                                 

   NAME:                                                                    ADDRESS:

                                                                                        SEE INSTRUCTIONS ON BACK

   Account                                                                  RETURN THIS COPY WITH PAYMENT
                                                                                    City of               Daviess 
   Period Ending                                                            Owensboro                     County
                                                                            Column A                      Column B
   Due Date

1. Total Gross Wages, Salaries and Other Compensation Paid

2. Less:  Compensation Not Subject to License Fee

   Earnings Subject to License Fee (Line 1 minus Line 2)             
3.
   (Include Section 125 "Cafeteria Benefits" as subject)

4. License Fee Rate
                                                                                    1.78%                 0.35%

5. License Fee Due (Line 3 Multiplied by Line 4)

6. Penalty (5% per month not to exceed 25%) $25 Minimum

7. Interest (1% per calendar month or fraction thereof)

8. Total Amount Due (Add Lines 5, 6, 7)

9. Total Amount Due (Add 8a and 8b)

   I hereby certify that the information statements contained herein and any schedule or exhibits attached 
   are true and correct to the best of my knowledge.

                   Signature                                                        Title                  Date

           MAKE CHECKS PAYABLE AND MAIL TO:                                 Occupational Tax Administrator
                                                                            PO Box 10008
                                                                            Owensboro KY  42302-9008
                                                                            (270)  687-5600

Who Must File - Each employer who employs one or more                 Important Note: Calculate the occupational license fee due from
individuals shall withhold the occupational license fee due from each compensation earned within the corporate city limits of the City of
employee on salaries, wages, commissions and other compensation       Owensboro in Column A of FORM E- 1. Calculate the occupational
for work done or services performed or rendered in the City of        license fee due from compensation earned in Daviess County,
Owensboro and/or Daviess County.                                      outside the corporate city limits of Owensboro, in Column B 

When To File - The employer shall make a return and pay the           Line 1 - Enter compensation paid to employees, regardless of
license fee in accordance with the following due dates:               when or where earned.
                                                                      Line 2 - Enter the amount included in Line I which represents
a.) Returns required to be filed monthly shall be due on or before    payment for services performed:
the 15th day of the month next following each monthly period,                    - Outside the corporate city limits of the City
except the return for the last month of the calendar                  Owensboro on Line 2
year, which shall be due on January 31.                                            Column A
b.) Returns required to be filed quarterly shall be due on or before            - Outside Daviess County on Line 2 of Column B. (Should
the last day of the month following each quarterly period.            include compensation earned in the corporate limits of the City of
                                                                      Owensboro).
Other Subject Earnings - The occupational license fee shall be        Line 3 - Enter total earnings subject to license fee. (Line I minus
withheld on the compensations paid by the employer to the             Line 2 in each column).
employee including, but not limited to:                               Line 4 - License fee rate. 
a.) Deferred compensation under Sections 403(b), 401 (k) or 457 of    Line 5 - Enter the License fee due. (Line 3 multiply by line 4 in each
the Internal Revenue Code.                                            column.
b.) Employee elections under Section 125 ''cafeteria plans''.         Line 6 - Applicable percentage of penalty multiplied by Line 5. (S25
c.) Disability, sickness and accident benefits paid by the employer.  minimum) (All licensees who fail to file and/or pay the license fee
d.) Vacation and/or holiday benefits.                                 by the due date shall pay penalty at the rate of 5% per calendar
e.) Cash and non-cash fringe benefits not otherwise exempt.           month, not to exceed 25% of the total license fee due, however
f.) Separation payments including an employer administered            penalty will always be a minimum of $25).
unemployment plan.                                                    Line7- Applicable percentage of interest multiplied by Line 5. (Any
g.) Life insurance premium for coverage in excess of $50,000, where   licensees who fail to pay the license fee by the due date shall pay
premiums are paid by the employer.                                    interest at the rate of 1% per calendar month, or fraction thereof,
                                                                      of any license fee due.
Exempt Earnings - No withholding of the occupational license          Line 8 - Total license fee, interest and penalty due. (Add Lines 5 6
fee shall be required for:                                            and 7 in each column).
a.) Domestic Servants.                                                Line 9- Total Payment due. (Add line 8 Column A to Line 8 Column
b.) Ordained Minister of Religion.                                    B) (PAY THIS AMOUNT WITH THE RETURN)
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.