EMPLOYEE’S INDIVIDUAL RETURN OF LICENSE FEE 
          UNDER CITY OF PADUCAH, KENTUCKY ORDINANCE ADOPTED 6-31-50, AMENDED 1-01-08 
                                                                     
 REPORT FOR YEAR ENDING                                                                                                                       
1. Total Earnings received during report period (Please attach W-2)                                                                      
 
2.  Earnings for Services Rendered outside Paducah.                                                                                      
3.  Taxable Earnings (Line 1 minus Line 2).                                                                                              
4.  Actual Fee (Line 3 multiplied by 2.0%).                                                                                              
5.  Penalty (5% per month of Line 4 not to exceed 25%) $25 Minimum.                                                                      
6.  Interest (1% of Line 4 per month).                                                                                                   
7.  Total Payment Due   Payable to:  City of Paducah, P.O. Box 9001241                                                                   
                                                                                           LOUISVILLE, KY 40290-1241                   

PAYMENT DUE BY 04/15/2019 
IF NO LONGER WORKING IN CITY LIMITS ENTER THE LAST MONTH AND YEAR WAGES PAID  ____/____                                                 

    The undersigned does hereby certify and attest under oath that the information and statements contained herein, and on any 
    attachments hereto, are true and accurate.  In making this sworn certification the undersigned acknowledge that in the event any of such 
    information and statements is not true and accurate, the undersigned may be prosecuted for a misdemeanor offense, and upon 
    conviction, may be subject to a fine up to $500.00 and/or imprisonment up to 30 days, all as prescribed in Section 106-195 of the 
    Paducah Code of Ordinances. 
     
    ____________________________________________________                      ______________________ 
    NAME                                                                ACCOUNT NUMBER 
     
    _____________________________________________________                      ______________________ 
    SIGNATURE                                                                                                          DATE 
     
         W-2 MUST ACCOMPANY RETURN