CITY OF SCOTTSVILLE, KY - OCCUPATIONAL TAX                                                                           20
Make Check Payable And Mail To:                                                                                                                                                      CHECK      CASH
City of Scottsville                  Net Profits Occupational Tax Return
201 W. Main, Suite 8
Scottsville, Ky 42164                FROM BUSINESS, PROFESSION, OR OTHER ACTIVITY WITHIN
                                SCOTTSVILLE, KY. CONDUCTED BY CORPORATIONS, PARTNERSHIPS,
Information Request                  INDIVIDUALS AND FIDUCIARIES OF ESTATES AND TRUSTS.
Ph: 270-237-4472                                  (RESIDENT OR NON RESIDENT)
Fx: 270-237-4922
                                     CALENDAR YEAR ENDED DECEMBER 31, 20
                                                                              OR
                                                  FISCAL YEAR INDICATED BELOW
This return must be filed with full payment of the fee on or before May 15 of each year, Return even if a net loss or copy of extension.
                                                                                                                                MO.         DAY          YR.

(PRINT NAME AND ADDRESS ABOVE - CHANGE IF NOT CORRECTLY SHOWN)

Give Trade Name, If Any
Nature of Business

                                                                                                                         SOCIAL SECURITY # OR
                                                                                                                         FEDERAL IDENTIFICATION #.                                No.
QUESTIONS (ANSWER FULLY)                                                                                                 3.  Check Which:   Corporation   Sub-Chapter S   Partnership
1.  Did you have employees in Scottsville during year?        Yes          No                                            Individual Owner             Fiduciary             Other (state)
2.  Has Scottsville License fee been withheld from all subject      Employees,                                           4.  Basis on which this Return is Prepared-Cash    Accrual 
and Remitted Quarterly in Accordance with these Regulations?                                                             5.  Have Federal Authorities Changed the Net Income as Originally
Yes         No          If Answer is “No” Explain                                                                        Reported for Any Prior Year?      Yes    No
                                                                                                                         If Answer is “Yes” Attach Schedule of Changes for Each Year.

                                                                              SCHEDULE A
1. Net Business Income per Federal Return.................................................................               $                                                        (Do not write in this space)
2. ADD Items not deductible (Line G, Schedule B)...................................................
3.  Total (Line 1 plus Line 2)...........................................................................................
4.  DEDUCT items not subject (Line N, Schedule B).................................................   
ADJUSTED NET BUSINESS INCOME (Line 3 less Line 4)..............................                                          $
6. If Sch.C (Line 4) is used enter here AVERAGE
PERCENTAGE...........................................................................................................                                       %
7. NET PROFITS Subject to Scottsville
License Fee (Line 5 x Line 6).....................................................................................       $

                                     8.   Scottsville License                                                                                                                    $
                                                  Fee at 1.5% of amount on Line 7..............................................................................
                                     9.   Minimum License Fee ..........................................................................................                                   30 00
                                     10. Interest 1/2 of 1% per month if paid after due date................................................
                                     11.  Penalty - 1% per month not exceeding 10% if paid 30 days after due date.........
                                     12.  Total (Lines 8+9+10+11).........................................................................................                       $
                                     13.  Less credits - ESTIMATED PMTS..........................................................................
                                     14.  Less credits - ADVANCE LICENSE FEE..............................................................
                                     15.  BALANCE DUE. . PAY THIS AMOUNT..............................................................
                                     16. OVERPAYMENT REFUND                                                              CREDIT ................................................ $

34240MS - UNITED SYSTEMS & SOFTWARE, INC. - BLACK INK

                                                                          SCHEDULE B
NOTE: ADD AND/OR DEDUCT ONLY THOSE ITEMS WHICH ARE INCLUDED IN CALCULATING NET INCOME
ITEMS NOT DEDUCTIBLE - ADD                                                 ITEMS NOT SUBJECT - DEDUCT
A. Federal or Local taxes based on income............ $                   H.  Interest on Corporate Bonds................................                                              $
B.  License Fee under this Ordinance......................                I.   Interest on U.S. Government Securities.............
C.  Ordinary Gain.......................................................  J.   Royalties on Patents, Copyrights.........................
D.  Net Operating Loss Deduction...........................               K.  Dividends...............................................................
E.  Partners’ Salaries (attach schedule)....................              L.   Ordinary Loss........................................................
F. Other items (list).................................................... M.  Other (attach schedule)........................................
G. TOTAL ADDITIONS (enter on Line 2)...........                           N.  TOTAL DEDUCTIONS (& enter on Line 4)..                                                                   $

                                                                          SCHEDULE C
Business Allocation Percentage - Divide (Col. A) by (Col. B) to obtain decimal. Carry out at least 6 places.
ALLOCATION FACTORS                                                         ColumnScottsvilleA  TotalColumnEverywhereB                                                                  PERCENTAGEColumn C(A+B)
                                                                                              $
1.  Total Net Business Profits Per Federal Returns                        $
2.  Total Wages, Salaries and Other Personal Service
Compensation Paid to Employees.

3.  TOTAL PERCENTS: Add Lines 1,2 ....................................................................................................................................................                        %
4.  AVERAGE PERCENTAGE (Line 3 divided by 2)............................................................................Enter on Line 6......................                                                 %

                                                                          CERTIFICATE
Prepared By
I HEREBY CERTIFY That the statements made herein and any supporting schedule or exhibit are true, correct and complete.
(Signature of License Fee Payer)                                                               Date                                                                                    20 

34240MS - UNITED SYSTEMS & SOFTWARE, INC. - BACKER BLACK INK