PULASKI COUNTY, KENTUCKY QUARTERLY LICENSE FEE RETURN
I hereby certify that the information & statements contained herein & any schedules or exhibits 
attached are true & correct.                                          For Quarter Ending:  ___________________

Company Name: ____________________________________________________________

Federal ID No. or SS Number: _______________________________  No of Employees: _________

Address: _____________________________________________________________________

City State: __________________________________________  ZipCode: ________________

Your Printed Name: _______________________________________________________________

Your Title: _____________________________  CONTACT # _______________________________

SIGNED _______________________________________________ DATE _____________________
                   PLEASE CHECK ALL APPLICABLE BOXES
  I.D. # Change ______________________________________________
NO ACTIVITY  ( This form must be returned even if there is no activity for this quarter )
FINAL RETURN (indicates all taxes have been paid)
Change Address to: 

{ INSTRUCTIONS FOR FOURTH QUARTER RETURN}
By February 28th you must remit a reconciliation statement with name, social security #, 
& gross wages for each employee and a copy of your Federal W-3.      W-2's may be used
 in lieu of reconciliation. Federal employees must remit W-2 and pay all taxes due for the 
preceding year by February 28th.
MAKE CHECK PAYABLE TO AND REMIT TO : TAX ADMINISTRATOR 
P.O. BOX 658 SOMERSET, KY 42502-0658 ( FOR INFORMATION CALL 606-679-2393 )

1  Total Pulaski County Wages & Compensation
   (Total Wages & compensation less wages earned outside Pulaski County)

 2 Wages earned inside Somerset City Limits

   a) Total County Tax Due (inside city)   (line 2 x .008)  [.8%]                        0

3  Wages earned inside Pulaski County (Line 1 minus Line 2)

   a) Total County Tax Due (inside county)   (Line 3 x .01)    [1%]                      0

4  Grand Total of Occupational Tax Due (Line 2a + Line 3a)                               0

5  PENALTY = 5% of the tax due (per month or fraction thereof)
   ($25.00 min or 25% max) Penalty and interest apply if not paid by due date.
 6 INTEREST = 12% PER ANNUM

             TOTAL INCLUDING PENALTIES AND INTEREST                                      0

PLEASE RETURN ORIGINAL AND RETAIN A COPY FOR YOUR RECORDS
                                                                              PRINT
DO NOT STAPLE CHECK TO THIS RETURN
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