SIMPSON COUNTY TAX ADMINISTRATOR                                        HOW TO RECONCILE YOUR PAYROLL WITHHOLDINGS
                                                                 Enter under SUBJECT PAYROLL the quarterly totals of all employees for services within Carroll
   RECONCILIATION OF LICENSE FEE WITHHELD                        County.  Deduct $5,000 for each such employee, and enter the balance for each quarter under
   DURING YEAR ENDED                                             TAXABLE PAUROLL.  All compensation, i.e.,Vacation, Sick, and Holiday Pay, is to be included
   *PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS*            in the payroll totals.
                                                  TOTAL PAYROLL            SUBJECT PAYROLL                                                                                    TOTAL PAYROLL
1. 1st Quarter ended Mar. 31................... $                $                                   X 1% =                                                                 $
                                                                                                                                                                                           0.00
2. 2nd Quarter ended June 30.................. $                 $                                   X 1% =                                                                 $              0.00
3. 3rd Quarter ended Sept. 30.................. $                $                                   X 1% =                                                                 $              0.00
4. 4th Quarter ended Dec. 31................... $                $                                   X 1% =                                                                 $
                                                                                                                                                                                           0.00
5. TOTAL ALL QUARTERS..................... $                     $                                                                                                          $              0.00
6. Actual withholding payments made quarterly on Occupational Tax Form.................................................................................................
7. Difference between lines 5 and 6 (if any, check applicable block below).................................................................................................                0.00
8. Number of employees Signature                                                       Title                                                                                  Date
                                                  Account Number                       Any balance due is to be paid and shown on
                                                                                       OCC-3PT Form line 3, as an adjustment.
                                                  Federal ID No.                       Any overpayment is to be:
                                                  Phone Number                               credited to next quarter
                                                                                             refunded
                                                                           To Be Filed With The 4th Quarter's Return By January 31                                                         SCREC

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