EMPLOYEE’S INDIVIDUAL RETURN OF LICENSE FEE 
    UNDER CITY OF PADUCAH, KENTUCKY ORDINANCE ADOPTED 6-31-50, AMENDED 1-01-08 

1. Total Earnings received during report period (see below)                                 
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 Treasurer, P.O. Box 2267, Paducah, KY 42002-2267  
                                                             
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 106-193 of the Paducah Code of Ordinances. 
 
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DATE                                    SIGNATURE