Fax: (859) 387-7651

                                  SIMPSON COUNTY TAX ADMINISTRATOR
                                  EMPLOYER'S RETURN OF LICENSE FEE WITHHELD
                                           If no wages were paid this period, mark "NONE" and return this form
1. Salaries, wages, commissions & other compensation                        7. Overpayment to be credited to next quarter      $ _____________
   paid all employees for services in Simpson County      $ _______________
2. Tax Due at - 1.00%                                     $ _______________
3. Adjustment for preceding quarters  (past due balances /
   underpayments)                                         $ _______________    I hereby certify that the information, schedules, statements and exhibits filed
4. Penalty (Min. $25.00) - 5.00%                          $ _______________    herewith are true and correct.
5. Interest (per annum) -  12.00%                         $ _______________    Signed   _____________________________________________________
6. BALANCE DUE                                            $ _______________    OfficialTitle   ________________________________   Date  ___________
                                                          Account No.          FOR PERIOD ENDING                               Make checks payable
                                                                               Month          Day            Year                and mail to:
                                                          Phone Number                                                         SIMPSON COUNTY TAX
                                                                                                                                ADMINISTRATOR
                                                                               RETURN DUE ON OR BEFORE                          P.O. BOX 242
                                                                               Month          Day             Year        FRANKLIN KY 42135-0242
                                                                                                                          Phone: (270) 586-7184
                                                                                                                          Email:
Indicate any name or address change above.                                     FED ID No.                                      nlaw@simpsoncounty.us
                                           *PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS.                             Form OCC-3PT Rev. 09/25/19

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