CITY OF RUSSELLVILLE, KENTUCKY 
                  P. O. Box 434 * Russellville, KY  42276 
               270-726-5002 (ph) * 270-726-5064 (fax) * www.russellvilleky.org 
                                          
            ANNUAL RECONCILIATION OF PAYROLL WITHHOLDINGS FOR PRIOR YEAR 
                  Please return to the City by the end of February 
 
EMPLOYER:  ________________________________________________________________________________________________________ 
 
ADDRESS:   _________________________________________________________________________________________________________ 
 
            _________________________________________________________________________________________________________ 
 
ACCOUNT NUMBER: _________________________________    
   
Fill out only one of the two columns determined by whether you remit your withholdings monthly or quarterly. 
               ATTACH A COPY OF EACH W-2 FORM OR STATEMENT FOR THIS JURISDICTION ONLY 
      ALSO ATTACH A COPY OF EACH 1099-MISC ISSUED BY YOUR COMPANY FOR BUSINESS ACTIVITY IN 
                                    THE CITY OF RUSSELLVILLE 
       
           PAID MONTHLY……………… OR …….. PAID QUARTERLY                            
       
January        ___________________ 
February        __________________ 
March          ___________________        1 st____________________              
       
April          ___________________ 
May            ___________________ 
June           ___________________        2 nd____________________              
                                                              
July           ___________________   
August         ___________________ 
September      ___________________        3 rd____________________              
                
October        ___________________ 
November       ___________________ 
December       ___________________        4 th____________________ 

TOTAL DUE      _______________________  TOTAL DUE _______________________       
 
TOTAL PAID     _______________________  TOTAL PAID_______________________ 
 
ADJUSTMENT     _______________________  ADJUSTMENT _____________________ 
 
If you have an ADJUSTMENT of less than $1.00 you do not need to pay the difference in taxes; 
however, if more than that, please attach a check or money order to CITY OF RUSSELLVILLE.